A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)
Stop the transfusion.
Place the client in high-Fowler's position.
Obtain a prescription for a diuretic.
Administer oxygen to the client.
Administer epinephrine to the client.
Correct Answer : A,B,C,D
A. Stop the transfusion. The first action is to stop the transfusion to prevent further fluid overload.
B. Place the client in high-Fowler's position. This position reduces venous return to the heart and improves breathing and oxygenation.
C. Obtain a prescription for a diuretic. Diuretics (e.g., furosemide) help remove excess fluid, relieving pulmonary congestion and reducing strain on the heart.
D. Administer oxygen to the client. Oxygen helps relieve hypoxia caused by fluid buildup in the lungs.
E. Administer epinephrine to the client. Epinephrine is used for anaphylactic reactions, not circulatory overload. There is no indication of an allergic reaction in this scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "A narrow base of support is recommended for effective lifting." A wide base of support provides more stability and balance, reducing the risk of injury.
B. "Make sure to bend at the waist when lifting objects more than 30 pounds." Bending at the knees, not the waist, helps maintain a neutral spine and prevents back strain.
C. "Use a twisting motion when moving objects to prevent back strain." Twisting while lifting can cause spinal injuries; instead, move the entire body by pivoting the feet.
D. "Stand close to a heavy object before attempting to lift it." Standing close to the object reduces strain on the back and improves control during lifting.
Correct Answer is D
Explanation
A. "I should close all doors and windows on the unit." –
This action is part of the "C" (Confine) step, which should be done before attempting to extinguish the fire.
B. "I should evacuate clients who are in immediate danger." –
Rescuing clients is the first step and should be done immediately.
C. "I should activate the facility's fire alarm system." –
Activating the alarm is the second step after rescuing clients.
D. "I should extinguish small fires if it is safe to do so." –
Extinguishing the fire is the last action in the fire safety protocol and should only be attempted if the fire is small and controllable.
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