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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Related Questions
Correct Answer is D
Explanation
A. "Previous caregiver experience." Experience may reduce stress by helping the caregiver develop coping strategies.
B. "25 to 50 years of age." Age alone is not a significant risk factor for caregiver burden.
C. "Lives in a different dwelling than the client." Caregivers living separately may experience less strain than those providing full-time, in-home care.
D. "Providing care for greater than 1 year." Long-term caregiving is associated with burnout, stress, and physical health issues, increasing the caregiver's risk of anxiety, depression, and chronic illness.
Correct Answer is C
Explanation
A. "The food is not great, but it is nice not having to do all of my own cooking." This statement shows acceptance by acknowledging both the challenges and benefits of the transition.
B. "When I go out, I've been using public transportation since I can't drive anymore." This reflects adaptation to the changes by finding alternative transportation.
C. "I don't want to go to the activity room because none of the other residents can hear." This suggests social withdrawal and frustration, which may indicate difficulty accepting the transition to assisted living.
D. "The staff sometimes have to remind me to use a cane when I walk in the hall." This shows acceptance of help from staff, which suggests an adjustment to the new environment rather than resistance.
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