Difficulty: Medium
Average Score: 93%
Simulated
A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take?
Correct answer
A,B,C
Rationale
Correct Answer: A, B, C
Rationale:
A: Placing the client in high-Fowler's position helps improve lung expansion and oxygenation.
B: Administering oxygen is crucial to treat hypoxia and improve oxygen levels in the blood.
C: Stopping the transfusion is necessary as the client is showing signs of fluid overload, which can lead to heart failure.
Incorrect choices:
D: Administering a diuretic may worsen the situation by further decreasing fluid volume.
E: Administering epinephrine is not indicated for these symptoms and can worsen the client's condition.
Rationale:
A: Placing the client in high-Fowler's position helps improve lung expansion and oxygenation.
B: Administering oxygen is crucial to treat hypoxia and improve oxygen levels in the blood.
C: Stopping the transfusion is necessary as the client is showing signs of fluid overload, which can lead to heart failure.
Incorrect choices:
D: Administering a diuretic may worsen the situation by further decreasing fluid volume.
E: Administering epinephrine is not indicated for these symptoms and can worsen the client's condition.