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?

Stop the transfusion.

Notify the health care provider of the client s response.

Check the client s vital signs.

Document the findings.

Answer and Explanation

The Correct Answer is A

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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Correct Answer is ["A","B","C","D","E"]

Explanation

A tracheostomy is a surgical procedure that involves creating an opening in the neck to establish a direct airway to the trachea. It is usually done in patients who require long-term mechanical ventilation or have upper airway obstruction. In case the tracheostomy becomes dislodged, the following equipment should be available to ensure the patient's safety:

Tracheostomy kit setup: This includes a new tracheostomy tube, obturator, and other equipment necessary to replace the dislodged tracheostomy tube.

Suction equipment: Dislodgement of the tracheostomy tube can cause airway obstruction due to the presence of secretions. Suction equipment can be used to remove the secretions and prevent airway obstruction.

Smaller Tracheostomy Tube and Same size Tracheostomy Tube: If the dislodged tracheostomy tube cannot be reinserted or is damaged, having smaller and same size tracheostomy tubes available can be helpful in establishing a new airway.

Ambu bag: This is a manual resuscitation device used to provide positive pressure ventilation to the patient. It can be used in case the patient's breathing is compromised due to airway obstruction.

Oxygen: The patient may require supplemental oxygen if their breathing is compromised due to airway obstruction.

Larger Tracheostomy Tube: A larger tracheostomy tube may not be needed immediately and may be contraindicated in some cases as it can cause trauma to the tracheal wall.

A. Ask the family to bring in hard cardies that help promote salivation and prevent dry mouth. B. Oﬀer him caﬀeinated tea since tea has diuretic properties it won’t aﬀect his ﬂuid restriction. C. Sip the water he is allowed to have slowly to make it last throughout the day. D. Drink as much Gatorade as he feels he needs to quench his thirst.

Correct Answer is C

Explanation

c. Sip the water he is allowed to have slowly to make it last throughout the day.

Option a is not recommended as hard candies may contain sugar and artificial sweeteners, which can be harmful to the patient's health.

Option b is not recommended because caﬀeinated tea has diuretic properties that can increase urine output, leading to further dehydration.

Option d is not recommended as Gatorade is a sports drink that contains high amounts of sugar and electrolytes, which can lead to ﬂuid overload and imbalances.

Sipping the water slowly can help the patient moisten his mouth without going over his ﬂuid restriction. This approach can also help him pace his ﬂuid intake throughout the day, which can be beneficial for maintaining proper hydration levels and managing ﬂuid overload.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are setting up a room for your patient that has a new tracheostomy. Select all of the equipment you need bring with to ensure patient is safe should the tracheostomy become dislodged:

Correct Answer is ["A","B","C","D","E"]

Explanation

A patient who is ordered a ﬂuid restriction of 1000ml ﬂuid restriction. He is on the list for a kidney transplant due to kidney failure. His mouth feels dry during the day. and he wants to know how he can moisten his mouth without going over his restriction:

Correct Answer is C

Explanation

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