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

Answer and Explanation

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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Correct Answer is B

Explanation

Cleanse hands with an alcohol-based hand rub before client contact. This action reduces the risk of transmitting microorganisms to the client who has a weakened immune system.

A. I will go barefoot just in the house B. I can use a heating pad when my feet are cold. C. I can apply lotion to my feet but avoid the area between my toes D. I will use a pumice stone to soften calluses on my feet

Correct Answer is C

Explanation

This statement shows that the client knows how to prevent dryness and cracking of the skin on the feet, which can lead to infection, while also avoiding excessive moisture between the toes, which can promote fungal growth.

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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.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is immunocompromised. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is providing instruction to a client who has diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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?

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