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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The correct answer is that the client should press the inner corner of their eye after inserting the drops. This technique is called punctal occlusion and it helps to prevent the eye drops from draining into the tear duct and being absorbed by the rest of the body. This can increase the eﬀectiveness of the eye drops and reduce potential side eﬀects.

Options b, c and d are not correct statements by the client that indicate an understanding of how to self- administer an ophthalmic solution. Raising the eyelid up while looking down to insert the drops, keeping eyes closed for 5 minutes after inserting the drops and inserting the drops in the center of each eye are not recommended techniques for self-administering an ophthalmic solution.

A. Invasion of privacy B. Negligence C. Assault D. Battery E. False imprisonment

Correct Answer is E

Explanation

The correct answer is that this situation represents false imprisonment. False imprisonment is the unlawful restraint of an individual's freedom of movement. In this case, the nurse placed the client in restraints without obtaining a prescription from the provider or following proper protocol, which constitutes false imprisonment.

Options a, b, c and d are not correct torts in this situation. Invasion of privacy, negligence, assault and battery are all legal terms that refer to diﬀerent types of wrongdoing, but they do not apply to this specific scenario.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 nurse is providing teaching to a client who is to self-administer an ophthalmic solution. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. This situation represents which of the following torts?

Correct Answer is E

Explanation

A nurse is caring for a group of clients whose primary languages are diﬀerent from the nurse's. For which of the following clients should the nurse provide written materials in the client's primary language?

A nurse is caring for a client who has chronic back pain and asks about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this treatment?

A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hours. Which of the following actions should the nurse take first?

A nurse is speaking with the partner of a client who is unconscious and has a do-not-resuscitate (DNR) order in place. The partner requests that CPR be performed if necessary. Which of the following responses should the nurse make?

A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

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 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 on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?