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.
Obtain a prescription for a diuretic.
Place the client in high-Fowlers position.
Administer epinephrine to the client.
Administer oxygen to the client
Correct Answer : A,C,E
Stop the transfusion, place the client in high-Fowlers position, and administer oxygen to the client. The rationale for these answers is that these actions are appropriate interventions for a client who is experiencing circulatory overload, which is a potential complication of blood transfusion characterized by fluid overload in the lungs and heart failure. Stopping the transfusion will prevent further fluid accumulation, placing the client in high-Fowlers position will facilitate breathing and reduce venous return, and administering oxygen will improve oxygenation and tissue perfusion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should encourage the client to make choices regarding hygiene, as this respects the client's autonomy and dignity. Suctioning the client's airway every hour is incorrect because it may cause discomfort and distress to the dying client. Offering the client sips of a citrus flavored soda is incorrect because it may irritate the client's mouth and throat, which are often dry and sensitive at the end of life. Positioning the client supine in bed is incorrect because it may increase the risk of aspiration and airway obstruction, as well as pressure ulcers.
Correct Answer is D
Explanation
The nurse should assess the client's vital signs first to determine if there are any signs of fluid overload, such as hypertension, edema, crackles, or dyspnea. The nurse should then notify the primary care provider.
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