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.)

Place the client in high-Fowler's position.

Administer oxygen to the client.

Stop the transfusion.

Obtain a prescription for a diuretic.

Administer epinephrine to the client.

Answer and Explanation

Correct Answer : A,B,C

A.   Placing the client in high Fowler's position helps improve lung expansion and oxygenation.
B.   Administering oxygen helps address hypoxia and supports adequate oxygenation.
C.   Stopping the transfusion is crucial when signs of a transfusion reaction are present.
D.   Administering a diuretic is not typically indicated for transfusion reactions involving lung crackles, hypoxia, and distended neck veins.
E.   Epinephrine is not typically used to manage a blood transfusion reaction; it's more for severe allergic reactions like anaphylaxis.

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Correct Answer is A

Explanation

A. Holding bottles of sterile solution with the label in the palm of the hand can risk contamination as it involves touching the label. B. Pouring liquids into containers outside the sterile field helps prevent contamination of the field. C. Placing the sterile field at the level of the nurse's hips might not be optimal; it's typically positioned above waist level to maintain sterility. D. Opening the outermost flap of the sterile kit toward the body minimizes the risk of the flap touching non-sterile surfaces during opening.

A. "I will weigh myself once weekly." B. "I will take my new medication in the evening." C. "I will leave a light on in my bathroom at night." D. "I will take a hot bath before going to bed."

Correct Answer is C

Explanation

A. Weighing once weekly might not be frequent enough for monitoring changes related to heart failure or medication effects.
B. The timing of hydrochlorothiazide administration isn't critical to safety considerations; it's typically taken in the morning due to its diuretic effect.
C. Leaving a light on in the bathroom at night can help prevent falls, a common concern in older adults, especially those with heart failure.
D. Taking a hot bath before bed might not contribute significantly to safety considerations related to heart failure or medication use.

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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 preparing to set up a sterile field. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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