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 C

Explanation

A. Starting a blood transfusion without obtaining consent is a violation but may fall more under the category of battery than negligence.
B. Preventing a client from leaving the facility might relate more to issues of false imprisonment or breach of autonomy rather than negligence.
C. Administering medication without properly identifying the client can be considered negligence as it breaches the standard duty of care.
D. Discussing client care in a public area with visitors present might breach confidentiality but might not be categorized as negligence unless sensitive or protected information was disclosed.

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.)

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Naxlex Comprehensive Predictor Exams

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