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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.)

Obtain a prescription for a diuretic.

Administer oxygen to the client.

Administer epinephrine to the client.

Stop the transfusion.

Place the client in high-Fowler's position.

Answer and Explanation

Correct Answer : A,B,D,E

A. Diuretics are used to reduce the fluid overload.

B. Administering oxygen helps alleviate hypoxia and support respiratory function.

C.   Epinephrine is not indicated for these symptoms and could exacerbate the situation.
D.   Stopping the transfusion is essential if transfusion-related complications are suspected.
E.   Placing the client in high-Fowler's position helps optimize respiratory function and reduce fluid overload.

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Correct Answer is B

Explanation

A. Asking about medication cessation is important but not as immediate as addressing the client's current state of mind.
B. This response directly addresses the client's statement of suicidal ideation and opens up a dialogue about their safety.
C. While discussing the partner may be relevant, it doesn't address the immediate safety concern.
D. Referring to the provider can be done later but ensuring immediate safety is the priority.

A. Dose B. Time C. Medication D. Route

Correct Answer is B

Explanation

A. The dose is specified in the prescription as 5mg.

B. The prescription does not specify how frequently or at what intervals the morphine should be administered.
C. The medication is clearly stated as morphine.

D. The route of administration is specified as intravenous.

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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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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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