The nurse is caring for a client receiving their second unit of Packed Red Blood Cells for an initial hemoglobin. The client appears flushed and complains of itching and urticaria. After following protocol (stopping transfusion, running 0.9% normal saline) and notifying the health care provider, the nurse would prepare to administer:

What action priority in preventing anaphylactic shock?

The nurse is testing the function of cranial nerve XI (Spinal accessory nerve). Which finding would the nurse expect if the nerve is intact?

The nurse cannot auscultate bowel sounds during the assessment of a client who has had a repair of an abdominal aortic aneurysm four days ago. The client is complaining of severe abdominal pain and the abdomen is distended. What action should the nurse take at this time?

A patient is ordered 1 unit of packed red blood cells (250mL) to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

The client admitted with sickle cell anemia crisis is being treated with a transfusion of 2 units of packed red blood cells (PRBC's) for a low hemoglobin. The cent demonstrating a new onset of chest pain. low back pain, tachycardia and anxiety. The nurse's immediate intervention is

How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

The nurse is caring for a client in the burn unit with burns to the head, neck, chest back left arm and hand following an explosion in their garage. Upon admission, the nurse auscultates wheezes throughout all lung fields and applies oxygen via non-rebreather. One hour later, upon reassessment, the patient is visibly anxious and short of breath, wheezes cannot be heard, lung sounds are decreased, voice is hoarse, and the client is coughing up gray sputum. What is the most appropriate nursing action?

The nurse is caring for a client who has an abdominal aortic aneurysm. The physician explains to the client that the aneurysm is small and that the client will be managed medically. Based on this information, it is most important that the nurse reinforces discharge teaching about:

The nurse in the emergency department is caring for a client with multiple injuries following a motor vehicle crash. The client lost consciousness. has an open fracture of the left tibia, and active bleeding at the fracture site. What is the priority nursing action?

The nurse is caring for a patient with muffled heart sounds, jugular venous distention and hypotension. The provider diagnoses the patient with cardiac tamponade. The nurse understands that the priority of treatment for this type of shock is