KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to ﬁnd initially before ﬂuid balance reaches homeostasis?

Crackles to Bilateral lobes

Tenting skin and wet mucous membranes

C Tachycardia and hypotension

+4 edema to bilateral lower extremities and confusion

Answer and Explanation

The Correct Answer is C

Dehydration can cause a decrease in blood volume, leading to a drop in blood pressure (hypotension) and an increase in heart rate (tachycardia) as the body tries to compensate. Tenting skin and dry mucous membranes are also signs of dehydration, but wet mucous membranes are not. Crackles in the lungs, edema, and confusion can occur with ﬂuid overload, but not with dehydration.

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Correct Answer is C

Explanation

A PICC line is a long, thin tube that’s inserted through a vein in your arm and passed through to the larger veins near your heart 1. If the PICC line is touching a chamber of the heart, it is most likely touching the right atrium 2.

A. Stop the transfusion. B. Notify the health care provider of the client s response. C. Check the client s vital signs. D. Document the findings.

Correct Answer is A

Explanation

Difficulty breathing is a sign of a potential transfusion reaction. When a client reports difficulty breathing during a blood transfusion, the nurse should stop the transfusion immediately to prevent the reaction from worsening. Once the transfusion is stopped, the nurse can then assess the client's vital signs and notify the healthcare provider of the client's response. Documentation of the findings should also be completed after the client's condition has stabilized. However, stopping the transfusion takes priority over documenting the findings.

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KO is admitted with severe dehydration and electrolyte unbalances. What assessment findings are you most likely to ﬁnd initially before ﬂuid balance reaches homeostasis?

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Correct Answer is C

Explanation

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

Correct Answer is A

Explanation

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