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.
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Related Questions
Correct Answer is B
Explanation
Parenteral nutrition (PN) with high concentrations of dextrose, such as 20%, requires a central venous line for administration to prevent damage to peripheral veins. Therefore, preparing the client for a central venous line is an appropriate action to include in the plan of care.
a. The PN infusion bag should be changed every 24 hours to reduce the risk of infection.
d. Blood glucose levels should be monitored regularly, but not necessarily daily, as PN can affect blood glucose levels.
c. PN and fat emulsions can be administered together in a single infusion.
Correct Answer is D
Explanation
When a nurse receives a new prescription over the telephone from a client's provider, the first action the nurse should take is to write down the complete prescription. This ensures that the nurse has an accurate record of the prescription and can refer to it when administering medication or providing care.
Option a is incorrect because documenting the prescription as a telephone prescription in the medical record is important but not the first action.
Option b is incorrect because reading back the prescription to the provider is important but not the first action.
Option c is incorrect because ensuring that the provider signs the prescription is important but not the first action.
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