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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Using a straw with thickened liquids can increase the risk of aspiration for a client with dysphagia.
B. Tucking the chin can help prevent aspiration and is a recommended technique for clients with dysphagia.
C. Taking frequent breaks while eating can be a beneficial strategy for clients with dysphagia to prevent fatigue and aspiration.
D. Adjusting the head of the bed to 90° is a recommended position for clients with dysphagia to aid in swallowing.
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.
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