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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E","F"]
Explanation
A. While elevated (104/min), it's essential, but not as critical as other findings.
B. The significant drop in blood pressure from 108/56 mm Hg to 88/56 mm Hg within 30 minutes is a cause for immediate concern.
C. The slight increase in temperature (from 37.6°C to 37.5°C) is important but not the most pressing concern.
D. Itching over the chest with urticaria (hives) suggests an allergic reaction, requiring urgent attention.
E. Swelling of the tongue is a severe sign of an allergic reaction and requires immediate intervention.
F. Clear and present breath sounds with scattered wheezing indicate potential airway compromise, requiring immediate follow-up.
Correct Answer is D
Explanation
A. Priming the IV tubing with lactated Ringer's isn't necessary for administering packed RBCs.
B. Confirming the client's identity with the blood bank technician is crucial but typically done before receiving the blood product.
C. Ensuring the client has a suitable IV catheter is important but isn't the priority before starting the infusion of packed RBCs.
D. Checking the blood product's compatibility with the client's blood type is critical to prevent adverse reactions before starting the infusion.
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