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: The presence of an area rug over a tile floor poses a tripping hazard, which is particularly dangerous for individuals with osteoporosis due to the increased risk of fractures from falls. The rug can easily slip or edges can curl, leading to potential accidents. Therefore, it is crucial for the nurse to address this issue to prevent falls.

B: Grab bars in the shower are a safety feature that assists individuals in maintaining balance and preventing slips, which is beneficial for a person with osteoporosis. There is no need for intervention as this is a recommended safety measure.

C: Storing prescriptions in a medication organizer is a good practice as it helps ensure that medications are taken correctly and on time. This is especially important for older adults who may have multiple prescriptions. Thus, no intervention is needed here.

D: Setting the hot water heater to 47° C (117° F) can pose a risk of burns, especially for older adults whose skin may be more sensitive and who may have a delayed reaction to withdraw from hot surfaces. However, this is not directly related to osteoporosis, and while it is a safety concern, it is not as immediately hazardous as a tripping risk.

A. Hold bottles of sterile solution with the label in the palm of the hand. B. Pour liquids into containers outside the sterile field. C. Place the sterile field at the level of the nurse's hips. D. Open the outermost flap of the sterile kit toward the body.

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.

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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

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Explanation

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