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 epinephrine to the client.

Administer oxygen to the client.

Obtain a prescription for a diuretic.

Stop the transfusion.

Answer and Explanation

Correct Answer : A,C,E

A. Place the client in high-Fowler's position: Placing the client in high-Fowler's position (sitting up at a 90-degree angle) can help improve oxygenation by optimizing lung expansion. This position facilitates better respiratory mechanics and can be beneficial for clients experiencing respiratory distress.

B. Administering epinephrine to the client: Epinephrine is not indicated for the management of fluid overload or transfusion reactions characterized by respiratory symptoms such as TRALI. Therefore, this action is not appropriate in this scenario.

C. Administer oxygen to the client: Hypoxia is a serious concern and requires immediate intervention. Administering oxygen will help improve oxygenation and alleviate respiratory distress.

D. Obtaining a prescription for a diuretic: While diuretics may be indicated in some cases of fluid overload, their use should be guided by the healthcare provider's assessment and prescription. Obtaining a prescription for a diuretic may be considered after the transfusion has been stopped and the healthcare provider has evaluated the client.

E. Stop the transfusion: The presence of lung crackles, hypoxia, and distended neck veins suggests fluid overload, which can be a sign of transfusion-related acute lung injury (TRALI) or circulatory overload. Stopping the transfusion is essential to prevent further fluid overload and worsening of respiratory symptoms.

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Correct Answer is C

Explanation

A. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:

While using an appropriately sized cuff is crucial for accurate blood pressure measurement, the width of the cuff should be about 40% of the circumference of the upper arm, not 50%. However, adjusting the cuff size is not the most immediate action to take when faced with an elevated blood pressure reading.

B. Reposition the client supine and recheck her BP:

Repositioning the client supine is not necessary for routine blood pressure measurement in a sitting position. Moreover, repositioning the client may not significantly affect the blood pressure reading, especially if the initial reading was obtained correctly.

C. Recheck the client's BP in her other arm for comparison.

When obtaining a blood pressure reading, it's important to confirm the accuracy of the measurement, especially if the reading is elevated. Checking the blood pressure in the other arm allows for comparison and helps identify any significant differences between the arms, which could indicate arterial abnormalities or other issues. This step ensures accuracy and helps in making appropriate clinical decisions.

D. Request that another nurse check the client's BP in 30 min:

Waiting 30 minutes to recheck the blood pressure is not the most appropriate action when faced with an elevated reading. Prompt reevaluation and comparison of blood pressure readings are essential for accurate assessment and timely intervention, especially if the initial reading indicates hypertension.

A. "I will move your joints to the point of mild pain." B. "I will repeat these movements 3 to 5 times." C. "I will move your joints quickly." D. "These movements will be performed once per day."

Correct Answer is B

Explanation

A. "I will move your joints to the point of mild pain." - This statement is incorrect. Passive ROM exercises should not be performed to the point of causing pain. Pain during passive ROM exercises can indicate that the movement is too forceful or beyond the client's range of motion, which can lead to injury or discomfort.

B. "I will repeat these movements 3 to 5 times." - This statement is generally correct. Passive ROM exercises are typically repeated several times during each session to help maintain joint mobility and prevent contractures. The specific number of repetitions can vary based on the client's needs and tolerance.

C. "I will move your joints quickly." - This statement is incorrect. Passive ROM exercises should be performed slowly and gently to avoid causing discomfort or injury to the client. Slow movements allow for better control and precision, ensuring that the joints are moved through their full range of motion without undue force.

D. "These movements will be performed once per day." - This statement is incorrect. Passive ROM exercises are usually performed multiple times throughout the day, especially for clients with decreased mobility. Regular and frequent sessions help prevent stiffness, maintain flexibility, and promote circulation in the joints.

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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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