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A nurse is caring for a client in a medical-surgical unit.

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.


 

Answer and Explanation

The Correct Answer is []

Condition:

  • Transfusion-associated circulatory overload (TACO)

Actions the Nurse Should Take:

  1. Stop transfusion (D): This is crucial to prevent further fluid overload and worsening symptoms.
  2. Administer furosemide (C): Furosemide is a loop diuretic that can help remove excess fluid and alleviate symptoms of fluid overload.

Parameters to Monitor:

  1. Weight (B): Monitor weight to assess for fluid retention and overload.
  2. Respiratory rate (C): Monitor respiratory rate closely for signs of respiratory distress such as dyspnea and increased effort.


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Related Questions

Correct Answer is B

Explanation

A. Alcohol use disorder. While alcohol use disorder can lead to various health issues, it is not a direct cause of hearing loss.

B. Prolonged exposure to loud noises. Prolonged exposure to loud noises is a well-known risk factor for noise-induced hearing loss. This includes occupational noise exposure and listening to loud music.

C. Exposure to environmental toxins. Some environmental toxins, like certain chemicals and heavy metals, can lead to ototoxicity, which can damage the auditory system and cause hearing loss.

D. Contact with excessive heat. Excessive heat exposure is not directly linked to hearing loss. Hearing loss is more related to factors like noise exposure, ototoxic substances, and infections.

Correct Answer is B

Explanation

A. Notifying the provider: This is important but should be done after stopping the transfusion.

B. Stopping the transfusion. Chills and back pain during a blood transfusion can indicate a serious transfusion reaction, such as an acute hemolytic reaction. The priority action is to stop the transfusion immediately to prevent further complications

C. Covering the client with a blanket: This addresses the symptom of chills but does not address the potential life-threatening reaction.

D. Assessing the client's skin for a rash: This is part of the assessment for transfusion reactions but is not the priority compared to stopping the transfusion.

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