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 ["B","D"]

Explanation

B. Vitamin D level- Low levels of vitamin D, as indicated by the client's 25-hydroxy D (vitamin D + D) levels below the reference range (24 ng/dL initially and 15 ng/dL at the 6-month follow-up), can contribute to osteoporosis. Vitamin D is essential for calcium absorption and bone health.

D. Activity level- The client reports a sedentary lifestyle and inability to exercise regularly. Lack of weight-bearing exercise can increase the risk of osteoporosis as weight-bearing exercises help maintain bone density.
A. Alcohol use- The client denies drinking alcohol, so alcohol use is not a risk factor in this case.
C. Lactose intolerant- Lactose intolerance does not directly increase the risk of osteoporosis. However, if the client avoids dairy products due to lactose intolerance, they may have lower calcium intake, which can affect bone health.
E. Smoking history- The client is described as a nonsmoker, so smoking is not a risk factor for osteoporosis in this case. Smoking is associated with decreased bone density and increased fracture risk.
F. Phosphorus level- Phosphorus levels within the normal range (3.4 mg/dL initially and 3.2 mg/dL at the 6-month follow-up) do not directly indicate increased risk for osteoporosis. However, phosphorus, along with calcium, is important for bone health.

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

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is caring for a client. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for osteoporosis? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

A nurse is teaching a client about progressing from a clear liquid diet to a full liquid diet. Which of the following food selections by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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