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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 D

Explanation

A. Holding one's breath when rising from a sitting position can lead to increased intra-abdominal pressure and is not a recommended practice.
B. While changing positions regularly is important for preventing complications of immobility, relying solely on a partner every 4 hours may not provide enough frequent movement.
C. Antiembolic stockings are typically worn to prevent blood clots during periods of immobility and should not be removed while in bed unless instructed by a healthcare provider.
D. Performing ankle and knee exercises every hour helps maintain joint mobility and circulation, reducing the adverse effects of immobility.

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

A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is reviewing a medication prescription that reads, "Morphine 5 mg IV bolus for pain". Which of the following components should the nurse clarify with the provider?

Correct Answer is B

Explanation

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