A nurse is planning care for a client who has bacterial meningitis. Which of the following interventions should the nurse implement?

Ensure the client's bed is positioned to greater than 45°.

Initiate airborne precautions.

Ensure lights are dimmed in the client's room.

Encourage frequent ambulation.

Answer and Explanation

The Correct Answer is C

A.   The head of the bed should be elevated to 30 degrees to reduce intracranial pressure.
B.   Bacterial meningitis is transmitted through hematogenous route and airborne precautions are not always necessary.
C.   Clients with meningitis may be sensitive to light, dimming the lights should be implemented to increase comfort by reducing stimuli.
D.   Encourage frequent ambulation is not appropriate for bacterial

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Correct Answer is D

Explanation

A. Weight gain occurs due to accumulation of fluid in the body due to back pressure into the system circulation.
B. Distended abdomen occurs due to fluid accumulation due to reduced stroke volume.

C.While confusion can be a symptom of decreased cardiac output, it's not as specific as dyspnea in this case. Confusion can have various causes, including hypoxia, electrolyte imbalances, or medication side effects.
D. This is a common symptom of left-sided heart failure. When the left ventricle fails to pump blood effectively, fluid backs up into the lungs, causing shortness of breath.

A. Administer oxygen to the client. B. Collect a urine sample. C. Stop the infusion. D. Check the client's vital signs.

Correct Answer is C

Explanation

C. Suspending the infusion of packed RBCs is essential to prevent further administration of the blood product that may be causing the adverse reaction. Stopping the infusion allows for further assessment and appropriate management of the client's symptoms.
A. The client's symptoms of chills, lower back pain, and nausea suggest a potential transfusion reaction rather than respiratory compromise.
B. Collecting a urine sample may be indicated to assess for hemolysis or kidney injury, which can occur as a result of a transfusion reaction. However, this action can be deferred until after immediate interventions to manage the suspected reaction.
D. While checking the client's vital signs is important in assessing the severity of the reaction and the client's overall condition, it is not the first action to take when a transfusion reaction is suspected.

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A nurse is planning care for a client who has bacterial meningitis. Which of the following interventions should the nurse implement?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output?

Correct Answer is D

Explanation

A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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