A nurse is caring for a client in a medical-surgical unit

A nurse is caring for a client in a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition:

Transfusion-associated circulatory overload (TACO)

Actions the Nurse Should Take:

Stop transfusion (D): This is crucial to prevent further fluid overload and worsening symptoms.
Administer furosemide (C): Furosemide is a loop diuretic that can help remove excess fluid and alleviate symptoms of fluid overload.

Parameters to Monitor:

Weight (B): Monitor weight to assess for fluid retention and overload.
Respiratory rate (C): Monitor respiratory rate closely for signs of respiratory distress such as dyspnea and increased effort.

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Correct Answer is A

Explanation

A. Avoid crowds - Neutropenic patients are highly susceptible to infections. Crowded places increase the risk of exposure to pathogens.

B. Eat plenty of fresh fruits and vegetables - While generally healthy, fresh fruits and vegetables can harbor bacteria, posing a risk for infection in neutropenic individuals. Cooked or properly washed and peeled produce is safer.

C. Take temperature weekly - Neutropenic patients should monitor their temperature daily, not weekly, to detect infections early.

D. Perform mild exercise, such as gardening - Gardening can expose individuals to soil-borne organisms that could lead to infections. Indoor exercises or those that don’t involve potential pathogen exposure are safer.

A. Hemolytic B. Allergic C. Febrile D. Bacterial

Correct Answer is A

Explanation

A. Hemolytic: Acute hemolytic transfusion reactions can occur quickly after starting a transfusion and present with symptoms such as fever, chills, headache, low back pain, tachycardia, and apprehension. It is a serious reaction caused by the destruction of transfused red blood cells.

B. Allergic: Allergic reactions to blood transfusions typically present with hives, itching, and anaphylaxis, not low back pain or tachycardia.

C. Febrile: Febrile reactions involve fever and chills but not typically headache or back pain.

D. Bacterial: Bacterial contamination of blood can cause fever and chills, but not specifically the symptoms of headache and low back pain described.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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