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.)

Obtain a prescription for a diuretic

Administer oxygen to the client.

Administer epinephrine to the client.

Stop the transfusion.

Place the client in high-Fowler's position.

Answer and Explanation

Correct Answer : A,B,D,E

A. Obtaining a prescription for a diuretic may also be necessary to manage fluid overload
B Administering oxygen is essential to correct hypoxia, which is indicated by the client's symptoms of lung crackles and hypoxia. Oxygen therapy helps improve oxygenation and alleviate respiratory distress.
D. Stopping the transfusion is crucial because the client's symptoms, including lung crackles, hypoxia, and distended neck veins, suggest a potential transfusion reaction, such as transfusion-associated circulatory overload (TACO).
E. Placing the client in high-Fowler's position, with the head of the bed elevated to 90 degrees or as high as tolerated, helps improve ventilation and reduce venous return to the heart, which can alleviate symptoms of fluid overload and respiratory distress.
C. Administering epinephrine is not indicated in this situation as it is typically used for anaphylactic reactions, not circulatory overload.

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Correct Answer is D

Explanation

D. Demonstrates empathy and validation of the client's feelings. It acknowledges the client's concerns and opens the door for further discussion about their worries and fears regarding the future. By actively listening and addressing the client's concerns, the nurse can help establish trust and rapport, which are essential for effective therapeutic communication.
A. May inadvertently minimize or invalidate the client's feelings by suggesting that their concerns are unwarranted or irrational. This response does not address the client's concerns and may hinder open communication.
B. This dismisses the client's concerns and may make them feel guilty or ashamed for worrying about their future. This response does not acknowledge the client's emotions and fails to provide support or reassurance.
C. Focuses solely on the physical aspect of the client's recovery and does not address their emotional concerns about the future. While encouragement to participate in physical therapy is important, it should be accompanied by acknowledgment and validation of the client's emotional needs.

A. Bananas B. Cooked vegetables C. Yogurt with fruit D. Pudding

Correct Answer is D

Explanation

D. A full liquid diet includes all foods that are liquid or will turn to liquid at room or body temperature. Pudding is an appropriate choice because it conforms to these criteria. While yogurt with fruit may seem like a suitable option, it typically contains chunks of fruit which do not meet the requirements of a full liquid diet.
A. Bananas are solid foods and are not typically included in a full liquid diet.
B. Cooked vegetables are solid foods and are not typically included in a full liquid diet.
C. Yogurt with fruit is a semi-solid food, it may not be appropriate for a full liquid diet depending on the consistency of the yogurt and the size of the fruit pieces.

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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

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