How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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:

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

Parameters to Monitor:

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


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

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.

Correct Answer is ["A","C","E"]

Explanation

A. Increased heart rate - Tachycardia can occur as the heart compensates for increased blood volume and the need to maintain effective circulation.

B. Increased hematocrit - Hematocrit usually decreases in fluid overload because the increased plasma volume dilutes the red blood cells.

C. Increased blood pressure - Excess fluid volume often leads to hypertension as there is more fluid for the heart to pump, increasing vascular resistance.

D. Increased temperature - Temperature is not directly affected by fluid overload; fever or changes in temperature are more likely related to infection or other inflammatory responses.

E. Increased respiratory rate - Fluid overload can cause pulmonary congestion and decreased oxygenation, leading to increased respiratory effort to maintain adequate oxygen levels.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register