The nurse is assessing a client with a history of heart failure who is receiving a unit of packed red blood cells. The client's respiratory rate is 33 breaths/min and blood pressure is 140/90 mm Hg. Which action does the nurse take first?
a. Administer prescribed diphenhydramine (Benadryl).
b. Continue to monitor the client's vital signs.
c. Stop the infusion of packed red blood cells.
d. Slow the infusion rate of the transfusion.
D
Circulatory overload can occur when a blood product is infused too quickly. Adults with a histo-ry of heart failure are at risk for this. Management of this complication can be achieved by in-fusing the blood products more slowly. The client is not having an allergic reaction to the blood; therefore the blood should not be stopped nor should diphenhydramine be administered.
You might also like to view...
In the interview process, you should:
A. Be vague about experiences. B. Not exaggerate your knowledge and skills. C. Talk in abstract terminology. D. Defend your ability to do this job.
A primiparous client is being seen in the OB clinic for her first prenatal visit. It is determined that she is 11 weeks' pregnant. The nurse develops a teaching plan to address what the client will most likely experience during this period
Which of the following would the nurse include? A) Ankle edema B) Frequency C) Backache D) Hemorrhoids
An unlicensed assistive personnel (UAP) could be safely entrusted to perform which type of suctioning?
1. Oral cavity suctioning 2. Nasotracheal suctioning 3. Endotracheal suctioning 4. Tracheostomy suctioning
A patient of the American Indian heritage is diagnosed with liver cirrhosis caused by chronic alcoholism. For which problems would the nurse focus when discussing the patient's care with the spouse? Select all that apply
1. Domestic violence 2. Sexual abuse 3. Battering of women 4. Unplanned pregnancy