While administering a blood transfusion, the client receiving the blood postoperatively displays manifestations of dyspnea, dry cough, and pulmonary edema.
What is the priority action for the nurse to take?
Stop the transfusion immediately, obtain a culture of the client's blood, and administer antibiotics immediately.
Stop the transfusion immediately, notify the health care provider, monitor vital signs, and administer acetaminophen.
Stop the transfusion immediately, notify the health care provider immediately, and administer Lasix.
Stop the transfusion immediately, monitor vital signs, notify the health care provider, and place the client in an upright position with their feet dependent.
The Correct Answer is D
Choice A rationale
The manifestation of dyspnea and pulmonary edema points toward circulatory overload rather than a bacterial contamination or hemolytic reaction. Administering antibiotics and obtaining blood cultures are specific interventions for sepsis or transfusion-transmitted infections. These steps do not address the immediate mechanical fluid volume excess or the respiratory distress caused by fluid backing up into the pulmonary vasculature. Therefore, this is not the priority action for this client.
Choice B rationale
Acetaminophen is primarily used to treat febrile non-hemolytic transfusion reactions by inhibiting prostaglandin synthesis in the central nervous system. While stopping the transfusion is a required first step for any reaction, administering an antipyretic does not treat the acute pulmonary edema or respiratory distress described. This intervention fails to address the underlying physiological crisis of volume overload, which requires aggressive positioning and fluid management rather than fever reduction or mild analgesia.
Choice C rationale
While Lasix is a loop diuretic often used to treat transfusion-associated circulatory overload by promoting rapid diuresis and reducing preload, the nurse cannot administer it without a specific provider order. While notifying the provider is correct, the immediate nursing priority involves independent actions to optimize oxygenation. This choice skips the vital step of positioning the client to improve lung expansion and reduce venous return before the medication can be obtained and administered.
Choice D rationale
The symptoms described are classic indicators of Transfusion-Associated Circulatory Overload. In this condition, the rapid infusion of volume exceeds the cardiac output capacity, leading to increased pulmonary capillary hydrostatic pressure. Placing the client in an upright position with feet dependent uses gravity to reduce venous return to the heart and allows for maximum chest expansion. This independent nursing action directly addresses the respiratory distress while waiting for further medical interventions or diuresis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Cold therapy induces local vasoconstriction, which reduces the diameter of blood vessels and decreases capillary permeability. This physiological response limits the leakage of fluid into the interstitial spaces, thereby minimizing edema and swelling at the injury site. Furthermore, the reduction in blood flow slows the inflammatory cascade and decreases the release of chemical mediators like histamine and bradykinin, which effectively reduces redness and provides an analgesic effect by numbing local nerve endings.
Choice B rationale
Cold application typically functions as a local anesthetic by slowing the conduction velocity of sensory nerve fibers. While the initial application of an ice pack might feel uncomfortably cold or produce a stinging sensation, the ultimate goal and expected outcome of cryotherapy is a significant reduction in pain. Increased discomfort would suggest a potential complication, such as cold-induced tissue damage or frostbite, rather than the intended therapeutic effect of soothing the injured area.
Choice C rationale
Cold therapy is designed to decrease vascularity and promote fluid retention within the vessels through constriction. An increase in serous drainage would imply an increase in capillary leakage or inflammatory exudate, which contradicts the intended physiological outcome of ice application. By stabilizing cell membranes and reducing hydrostatic pressure in the capillaries, cold therapy should lead to a drier wound environment and a decrease in the volume of drainage from a surgical incision.
Choice D rationale
Because cold causes the smooth muscles in the walls of the arterioles to contract, the resulting vasoconstriction actually helps to control minor bleeding rather than increasing it. Heat therapy would cause vasodilation and potentially increase bleeding, but cold is a standard intervention for promoting hemostasis. Any observation of increased bleeding following the application of ice would be an abnormal finding and could indicate that the cold has caused skin shivering or other unintended systemic reactions.
Correct Answer is A
Explanation
Choice A rationale
Autocratic leadership is characterized by individual control over all decisions with little input from group members. In this style, the leader dictates the tasks, roles, and procedures that the staff must follow. By ensuring that all nurses perform specific, pre-determined activities, the leader maintains strict control and hierarchy. This approach is often efficient in emergency situations where quick, decisive action is required without the time for group consensus or lengthy discussions among the nursing staff.
Choice B rationale
Encouraging pride and recognition for following policies is more aligned with transformational or transactional leadership styles. A transformational leader inspires staff to achieve excellence through a shared vision, while a transactional leader uses rewards to motivate compliance. While an autocratic leader expects policy adherence, the focus on building pride and internal motivation suggests a more nuanced approach to leadership that values the emotional buy-in of the nurses rather than just the execution of orders.
Choice C rationale
Ensuring that nurses are satisfied and motivated is a hallmark of democratic or servant leadership. These styles prioritize the well-being of the team and involve staff in decision-making processes to increase job satisfaction and morale. Autocratic leaders are typically less concerned with the individual satisfaction or motivation of the employees and are more focused on the completion of tasks and the maintenance of organizational structure and authority within the clinical environment.
Choice D rationale
Encouraging nurses to perform activities without supervision describes a laissez-faire leadership style. This "hands-off" approach provides the team with complete autonomy and minimal guidance from the leader. This is the opposite of autocratic leadership, where the leader is highly involved in directing every aspect of the work. Laissez-faire leadership can be effective with highly experienced and self-directed teams but lacks the centralized control and direction inherent in the autocratic leadership model.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.