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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
An ankle-foot orthotic can help prevent a plantar flexion contracture of the affected extremity in a client who has right-sided paralysis following a cerebrovascular accident. This device can help maintain the foot and ankle in a neutral position and prevent the development of a contracture.
a. A sequential compression device is used to prevent deep vein thrombosis and is not specifically designed to prevent contractures.
b. An abduction splint is used to maintain the hip in a neutral position and is not specifically designed to prevent contractures of the foot and ankle.
d. A continuous passive motion machine is used to promote joint mobility and is not specifically designed to prevent contractures of the foot and ankle.
Correct Answer is C
Explanation
The nurse should arrange for a video conference with an interpreter who speaks the client's language to provide discharge instructions. This ensures that the client receives accurate and complete information in a language they understand. The other
a. Assistive personnel may not be trained or qualified to provide medical interpretation.
b. Family members may not have the necessary medical knowledge to accurately translate medical information.
d. Simply indicating printed instructions in the client's language may not be sufficient to ensure the client understands the information.
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