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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Assault refers to the threat or apprehension of harmful or offensive contact with another person. In this scenario, the nurse's statement of threatening to administer medication by injection if the client doesn't comply with swallowing pills constitutes assault.
A. Invasion of privacy refers to the unauthorized intrusion into an individual's private affairs. While the nurse's statement may be inappropriate and unprofessional, it does not directly involve intruding into the client's private affairs.
B. The threat of administering medication by injection without consent is an act that could be considered harmful or offensive, and it's done to coerce compliance, which is not ethically or legally appropriate.
C. Defamation involves the communication of false statements about a person that harm the person's reputation. In this scenario, the nurse's statement does not involve making false statements about the client to harm their reputation.
Correct Answer is C
Explanation
C. Positioning the client on their side with the right side of the chest elevated helps to promote drainage of the left lower lobe by allowing gravity to assist in the movement of secretions toward the larger airways for expectoration or suctioning.
A. Prone positioning involves lying face down, which may not effectively target drainage of the left lower lobe. Additionally, placing pillows under the lower extremities may not be conducive to drainage of the affected lung segment.
C. The supine position (lying flat on the back) does not facilitate drainage of specific lung segments, and the low-Fowler's position (semi-reclined with the head of the bed raised slightly) may not provide optimal drainage for the left lower lobe.
D. Trendelenburg position involves lying flat on the back with the legs elevated higher than the head. While this position may help improve venous return and cardiac output in certain situations, it is not specifically indicated for postural drainage of the left lower lobe.
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