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 D
Explanation
A. Explain the techniques of esophageal speech.Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.
B. Schedule a support session for the client.While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.
C. Determine the client's reading ability.This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.
D. Review the use of an artificial larynx with the client.This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.
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.
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