A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Slow infusion rate and contact the provider.

Lower the head of the bed to semi-Fowler's.

Administer prescribed corticosteroids.

Change infusion to lactated Ringer's and maintain rate.

Answer and Explanation

The Correct Answer is A

A.   The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B.   Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C.   Administering corticosteroids is not indicated based on the client's symptoms and situation.
D.   Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.

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Correct Answer is B

Explanation

A) Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B) Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C) Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D) Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.

A. Distended jugular veins B. Pitting, dependent edema C. Decreased blood pressure D. Increased blood pressure

Correct Answer is C

Explanation

A) Distended jugular veins are associated with fluid overload, not dehydration.

B) Pitting, dependent edema is also associated with fluid overload, not dehydration.

C) Decreased blood pressure is a common sign of dehydration due to decreased blood volume.
D) Increased blood pressure is not typically associated with dehydration and may suggest other conditions such as hypertension or fluid overload.

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A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is C

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