The client who is receiving a blood transfusion tells the nurse her chest feels tight. The nurse observes that she is short of breath and her temperature is elevated. What initial action should the nurse take?
1. Report the findings to the physician.
2. Check the client again in 15 minutes.
3. Stop the transfusion.
4. Increase the flow rate of the transfusion.
ANS: 3
You might also like to view...
A nurse is providing emergency care to an assault victim. Which of the following would be the most appropriate action for the nurse to take?
a. Support the privacy of the victim b. Assess the socioeconomic status of the victim c. Question the victim about the details of the assault d. Educate the victim about violence preven-tion
The nurse recognizes that the primary effect of pregnancy on a woman with a preexisting heart disease is:
a. The shunting of blood to the fetus reduces the mother's cardiac workload. b. Increased renal blood flow, which promotes elimination of excess fluid. c. Decreased venous return, which decreases blood pressure. d. The workload of the heart is greatly increased.
The patient is receiving human serum albumin (Albutein) as treatment for shock. What is a priority assessment by the nurse?
1. Auscultate breath sounds for hyper-resonance. 2. Auscultate for an absence of breath sounds in the lower lobes. 3. Auscultate breath sounds for inspiratory stridor. 4. Auscultate breath sounds for crackles.
The term that describes a substance that is soluble in fat is called
A. insipid-soluble B. lipid-soluble C. capillary-soluble D. monolipid-soluble