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 ["475 "]
Explanation
To calculate the client's intake for that 4-hr period in ml, we need to convert the liquid amounts from oz to ml using the following formula:
1 ml = oz * 29.5735296
Using this formula, we can convert the milk, orange juice, tea, and water amounts to ml: Milk: 3 oz * 29.5735296 ml/oz = 88.7205888 ml
Orange juice: 2 oz * 29.5735296 ml/oz = 59.1470592 ml
Tea: 3 oz * 29.5735296 ml/oz = 88.7205888 ml
Water: 4 oz * 29.5735296 ml/oz = 118.2941184 ml
The total intake from these liquids is:
88.7205888 + 59.1470592 + 88.7205888 + 118.2941184 = 354.8823552 ml We also need to add the intake from the IV infusion, which is given at a rate of 30 mL/hr for 4 hours:
30 mL/hr * 4 hr = 120 mL
The total intake from the IV infusion is:
120 mL
The total intake for that 4-hr period in ml is:
354.8823552 + 120 = 474.8823552 ml
Rounding the answer to the nearest whole number, we get:
475 ml
Correct Answer is A
Explanation
When caring for a client who has restraints, the nurse should follow the ABCDE priority-setting framework and assess airway, breathing, circulation, disability, and exposure first. Peripheral pulses are an indicator of circulation and should be assessed first to ensure adequate blood flow to the extremities. Comfort level, skin integrity, and elimination needs are also important assessments but are not as high priority as circulation.
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