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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 A

Explanation

A. Assault involves the threat of harm or unwanted touching, which is implied in the nurse's statement.
B. Defamation involves harming a person's reputation, which is not occurring in this scenario.
C. Invasion of privacy involves intruding upon a person's private affairs, which is not relevant here.
D. Battery involves actual unwanted touching, which has not occurred yet in this scenario.

A. Request that another nurse check the client's BP in 30 min. B. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference. C. Recheck the client's BP in her other arm for comparison. D. Reposition the client supine and recheck her BP.

Correct Answer is C

Explanation

A. While it's important to monitor elevated blood pressure, waiting 30 minutes without further assessment may delay necessary intervention.
B. Ensuring the correct cuff size is important for accurate blood pressure measurement but doesn't address the immediate need for clarification of the reading.
C. Rechecking the BP in the other arm can help confirm the accuracy of the reading and identify potential discrepancies.
D. Repositioning the client supine may not be necessary and may not provide additional information about the accuracy of the BP reading.

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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.)

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Naxlex Comprehensive Predictor Exams

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