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 C

Explanation

Tightening the abdominal muscles prior to moving helps to stabilize the spine and prevent back strain. This is an important technique for caregivers to use when assisting a client who is immobile and requires repositioning in bed.

a. Twisting at the waist while pulling the draw sheet can cause strain on the back muscles and should be avoided.

b. Keeping the legs straight does not provide more power in the lift and can also cause strain on the back muscles.

d. Placing the bed in the lowest position does not necessarily prevent back strain and is not related to the proper technique for repositioning a client in bed.

A. Determine the probability of intervention-related complications. B. Review the potential benefits and consequences of each intervention. C. Select an intervention that provides the greatest benefit and least risk. D. Identify possible nursing interventions that address the client's nausea.

Correct Answer is D, B, A, C

Explanation

When caring for a client who is nauseated and unable to eat after taking an antibiotic, the nurse should first identify possible nursing interventions that address the client's nausea. The nurse should then review the potential benefits and consequences of each intervention. The nurse should determine the probability of intervention-related complications. Finally, the nurse should select an intervention that provides the greatest benefit and least risk to the client.

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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 nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is nauseated and unable to eat after taking an antibiotic. Identify the steps the nurse should take to address the client's nausea. (Arrange the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is D, B, A, C

Explanation

A nurse is caring for a client who has a new diagnosis of a terminal illness. The client states, "I do not want any treatment. I would like to go home." Which of the following responses should the nurse make?

A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

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 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 providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

A nurse is caring for a client who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the formula?

A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?