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 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.

A. The client takes frequent breaks while eating. B. The client adjusts the head of their bed to 90°. C. The client tucks their chin when they swallow. D. The client drinks their thickened juice with a straw,

Correct Answer is D

Explanation

D. Drinking thickened liquids with a straw is not recommended for clients with dysphagia because it can increase the risk of aspiration. Straws may allow liquids to bypass the swallowing mechanism, potentially leading to aspiration pneumonia or choking. Therefore, the nurse should intervene and provide alternative methods for the client to consume thickened liquids, such as using a spoon or a specialized dysphagia cup with a controlled flow rate.
A. Taking frequent breaks while eating is a common strategy for clients with dysphagia to pace themselves during meals and reduce the risk of aspiration. This action is appropriate and does not require intervention from the nurse.
B. Adjusting the head of the bed to 90° is also appropriate for clients with dysphagia, as it helps optimize swallowing mechanics and reduces the risk of aspiration. This position facilitates the passage of food and liquids down the esophagus and into the stomach.

C. Tucking the chin when swallowing is a proper technique to help close off the airway and prevent aspiration during swallowing. This action promotes safe swallowing by directing the bolus of food or liquid toward the esophagus and away from the trachea.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has left lower-lobe atelectasis. In which of the following positions should the nurse place the client for postural drainage?

Correct Answer is C

Explanation

A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?

Correct Answer is D

Explanation

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