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 A
Explanation
A. Speech-language pathologists specialize in assessing and managing swallowing difficulties (dysphagia) after a stroke.
B. Social workers primarily address psychosocial aspects and may not directly manage swallowing difficulties.
C. Physical therapists focus more on mobility and physical rehabilitation.
D. Occupational therapists help with daily living activities but might not specialize in dysphagia management.
Correct Answer is C
Explanation
A. Avoiding exposure to the sun might decrease vitamin D synthesis, which is necessary for calcium absorption.
B. Decreasing intake of dairy products may decrease calcium intake, which could increase the risk of osteoporosis.
C. Regular weight-bearing exercises like walking help maintain bone density and reduce the risk of osteoporosis.
D. A daily calcium intake of 250 milligrams might be insufficient for osteoporosis prevention; the recommended daily intake varies based on age and gender.
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