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 A

Explanation

A. Check the blood product's compatibility with the client's blood type: Before administering packed red blood cells (RBCs) or any blood product, it is crucial to ensure that the blood product matches the client's blood type and is compatible. This is done to prevent transfusion reactions and ensure safe administration.

B. Prime the client's primary IV tubing with lactated Ringer's: While it is important to prime the IV tubing with an appropriate solution before starting the transfusion, this action does not directly indicate prior to the start of the infusion.

C. Check that the client has a small gauge IV catheter in place: Having an appropriate size and functioning IV catheter in place is important for administering blood products, but this action does not specifically indicate prior to the start of the infusion.

D. Confirm the identity of the client with the blood bank technician: Confirming the client's identity is an essential step in ensuring that the correct blood product is administered to the correct client. However, this action is typically done before the blood product is prepared and delivered to the client's location, rather than immediately before starting the infusion.

A. Place wet towels along the base of the door. B. Turn off any electrical equipment. C. Activate the facility's fire alarm. D. Direct a fire extinguisher at the fire.

Correct Answer is C

Explanation

A. Placing wet towels along the base of the door: While this action may help prevent smoke from entering or exiting the room, it is not the immediate priority. Activating the fire alarm takes precedence to alert others to the fire and initiate the appropriate response.

B. Turning off any electrical equipment: While turning off electrical equipment can reduce the risk of electrical fires, it is not the immediate priority. Activating the fire alarm is the first step to ensure the safety of everyone in the facility.

C. Activate the facility's fire alarm.

Activating the fire alarm is crucial because it immediately alerts others in the facility to the presence of a fire, enabling them to respond appropriately. This action initiates the facility's fire safety protocols, including evacuating the area and summoning professional assistance to extinguish the fire. The sooner the alarm is activated, the quicker the response can be, reducing the risk to individuals and property.

D. Directing a fire extinguisher at the fire: While using a fire extinguisher may be necessary to extinguish the fire, it should only be done after activating the fire alarm to ensure that emergency personnel are alerted and responding to the situation.

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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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