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.
Administer epinephrine to the client.
Obtain a prescription for a diuretic.
Administer oxygen to the client.
Correct Answer : A,B,D,E
The nurse should stop the transfusion, place the client in high-Fowler's position, obtain a prescription for a diuretic, and administer oxygen to the client. These actions can help manage the symptoms of transfusion- associated circulatory overload (TACO), which can occur when a client receives too much fluid too quickly during a blood transfusion.
c. Administering epinephrine is not an appropriate action for managing TACO. Epinephrine is used to treat anaphylaxis, which is a different type of transfusion reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
If a nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr and notices that the client's IV bag is empty at 1200, the first intervention the nurse should take is to assess the client's vital signs. This will help the nurse determine if the client is experiencing any adverse effects from the rapid infusion of fluids.
Option a is incorrect because notifying the primary care provider is important but not the first intervention.
Option c is incorrect because calculating the infused volume is important but not the first intervention.
Option d is incorrect because completing an incident report is important but not the first intervention.
Correct Answer is D
Explanation
The nurse should ask a second nurse to record her signature when wasting any unused portion of the controlled substance. This is a standard procedure for the safe handling and documentation of controlled substances.
a. The nurse should report any discrepancy in the count total of the controlled substance before administration, not after.
b. The wasted portion of the controlled substance should be disposed of according to facility policy, which may not involve placing it in a sharps container.
c. The count total of the controlled substance should be verified before removing the amount needed, not after.
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