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? (Select all that apply.)
Correct answer
A,B,D,E
Rationale
Correct Answer: A, B, D, E
Rationale:
A: Stop the transfusion - The client is showing signs of fluid overload, which can lead to heart failure. Stopping the transfusion is crucial to prevent further complications.
B: Place the client in high-Fowler's position - This position helps improve lung expansion and oxygenation, aiding in the management of hypoxia.
D: Obtain a prescription for a diuretic - Diuretics help eliminate excess fluid in the body, which is essential in managing fluid overload.
E: Administer oxygen to the client - Hypoxia indicates inadequate oxygen levels in the blood. Providing oxygen is necessary to improve oxygenation and prevent further complications.
Summary:
C: Administer epinephrine to the client - Epinephrine is not indicated for fluid overload or hypoxia in this scenario.
F: No option provided.
G: No option provided.
The correct actions focus on addressing the immediate concerns of fluid overload and
Rationale:
A: Stop the transfusion - The client is showing signs of fluid overload, which can lead to heart failure. Stopping the transfusion is crucial to prevent further complications.
B: Place the client in high-Fowler's position - This position helps improve lung expansion and oxygenation, aiding in the management of hypoxia.
D: Obtain a prescription for a diuretic - Diuretics help eliminate excess fluid in the body, which is essential in managing fluid overload.
E: Administer oxygen to the client - Hypoxia indicates inadequate oxygen levels in the blood. Providing oxygen is necessary to improve oxygenation and prevent further complications.
Summary:
C: Administer epinephrine to the client - Epinephrine is not indicated for fluid overload or hypoxia in this scenario.
F: No option provided.
G: No option provided.
The correct actions focus on addressing the immediate concerns of fluid overload and