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.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Lie on your back when sleeping - While specific sleeping positions might be recommended, lying on the back is not necessarily required unless specified by the surgeon.

B. Wash your hair 24 hr after surgery - Hair washing is usually advised against within the first 24-48 hours post-surgery to prevent infection and avoid disturbing the surgical site.

C. Resume your exercise routine - Exercise is typically restricted initially to prevent strain or injury to the surgical area.

D. Eat foods that are soft - Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging any packing or stitches, and promote comfort during the initial healing period.

A. Stop the infusion of blood, B. Inform the provider. C. Obtain a urine specimen. D. Notify the laboratory.

Correct Answer is A

Explanation

A. Stop the infusion of blood. The client’s symptoms suggest a possible acute hemolytic transfusion reaction, which is a life-threatening emergency. The first and most critical action is to stop the blood transfusion immediately to prevent further reaction and additional hemolysis.

B. Inform the provider: This is an important action but should be done after stopping the transfusion to prevent further complications.

C. Obtain a urine specimen: This is done to check for hemoglobinuria, but it is not the immediate priority.

D. Notify the laboratory: This is part of the follow-up procedure but should be done after stopping the transfusion and stabilizing the patient.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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