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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

When a hospice nurse is visiting a client who has terminal cancer, the statement "I miss him so much already" by the client's partner should be recognized as an indication of anticipatory grief. Anticipatory grief is the grief that occurs before a loss and can include feelings of sadness, longing, and missing the person who is dying.

Option b is incorrect because anger is a common emotion during the grieving process but does not necessarily indicate anticipatory grief.

Option c is incorrect because planning for the future does not necessarily indicate anticipatory grief.

Option d is incorrect because not discussing funeral arrangements does not necessarily indicate anticipatory grief.

A. The type of transmission-based precautions in place. B. The times for routine vital sign measurements. C. The client's background health history. D. The number of visitors the client had during the shift.

Correct Answer is A

Explanation

When providing change-of-shift report about a client who has shingles, the nurse should include information about the type of transmission-based precautions in place to prevent the spread of infection to other clients and staﬀ. Shingles is caused by the varicella-zoster virus and can be spread through direct contact with the rash.

The times for routine vital sign measurements may be important information to include in the report, but it is not specific to the client's condition of shingles.
The client's background health history may be important information to include in the report, but it is not specific to the client's condition of shingles.
The number of visitors the client had during the shift may be important information to include in the report, but it is not specific to the client's condition of shingles.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A hospice nurse is visiting a client who has terminal cancer. Which of the following statements by the client's partner should the nurse recognize as an indication of anticipatory grief?

Correct Answer is A

Explanation

A nurse at a long-term care facility is providing change-of-shift report to an oncoming nurse about a client who has shingles. Which of the following information should the nurse include in the report?

Correct Answer is A

Explanation

A nurse is preparing to administer a medication to a client. Which of the following should the nurse use as a client identifier?

A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuﬀ to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)

A nurse is caring for a client who is immunocompromised. Which of the following actions should the nurse take?

A nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?

A nurse is planning to provide discharge instructions to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take?

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.)

A nurse is providing instruction to a client who has diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is providing teaching about health promotion guidelines to a group of young adult male clients. Which of the following guidelines should the nurse include?