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","C"]

Explanation

A. Adjusting the oxygen flow rate helps maintain adequate oxygen levels, especially during exertion or increased dyspnea.
B. The antibiotics were discontinued on Day 4, so the duration of antibiotic therapy is not 10 days.
C. Storing the wrench with the oxygen tank ensures that it's readily available to adjust or replace the tank.
D. Placing the oxygen delivery system away from heat sources helps prevent potential fire hazards.
E. There is no specifications on the time to take steroid medications
F. The specific instructions for taking the antibiotics weren't provided in the scenario.
G. The scenario doesn't specify a decreasing dose regimen for the steroid medication.

A. Drink a cup of hot cocoa before bedtime. B. Exercise 1 hr before bedtime. C. Eat a light carbohydrate snack before bedtime. D. Take a 30-min nap daily.

Correct Answer is C

Explanation

A. Drinking a cup of hot cocoa before bedtime might not be advisable due to the caffeine content, which can interfere with sleep.
B. Exercising vigorously close to bedtime can increase alertness and make it harder to fall asleep.
C. Eating a light carbohydrate snack before bedtime, such as a small amount of cereal or a slice of bread, can promote sleep as carbohydrates increase the availability of tryptophan, which is a precursor to serotonin and melatonin, both associated with sleep.
D. Taking a nap during the day might interfere with nighttime sleep if done too close to bedtime.

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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

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