A nurse is monitoring a blood transfusion of packed red blood cells. Assessment reveals dyspnea, tachycardia, neck vein distention, and rales on chest auscultation. The nurse expects the administration of which drug? A. Dexamethasone (Decadron) B. Furosemide (Lasix) C. Propranolol (Inderal) D. Diphenhydramine (Benadryl)

Nursing assessment is a critical first step in managing a patient's care, particularly when dealing with complex procedures such as a blood transfusion. A thorough assessment involves systematic monitoring and evaluation of a patient's condition to detect any signs of a potential complication.

During a blood transfusion, a nurse must be vigilant for symptoms like dyspnea, tachycardia, neck vein distention, and rales. These symptoms can indicate a fluid overload or blood transfusion reaction, which can lead to severe health issues such as pulmonary edema or congestive heart failure. Prompt identification and interpretation of these signs are imperative for initiating appropriate interventions, such as medication administration or cessation of the transfusion.

The steps in ensuring an effective nursing assessment include obtaining a comprehensive patient history, performing a physical examination, monitoring vital signs meticulously, and being familiar with possible transfusion reactions. Furthermore, nurses should be adept at auscultation to recognize abnormal lung sounds like rales that suggest complications.

The administration of medication is a fundamental responsibility of nursing care, especially when a patient's condition changes acutely during procedures like blood transfusions. Understanding the pharmacological aspects of different drugs and their relevance to specific clinical signs is crucial.

When symptoms of fluid overload appear, as in the exercise, selecting the correct medication is vital. Here, the diuretic Furosemide (Lasix) is the optimal choice. Diuretics assist in eliminating excess fluid from the body through increased urine output. This action helps alleviate symptoms of fluid overload such as dyspnea and tachycardia, preventing further complications.

Proper medication administration also involves checking the correct dosage, the patient's identity, the medication's expiration date, and observing for any adverse reactions post-administration. Additionally, educating the patient about the purpose and potential side effects of the medication can improve compliance and outcomes. When administering drugs like diuretics, it is important to monitor electrolyte levels and renal function, ensuring the patient's safety.

Preparing for the National Council Licensure Examination for Practical Nurses (NCLEX-PN) necessitates a comprehensive understanding of nursing concepts, including assessment and medication administration. The exercise provided exemplifies the type of critical thinking and knowledge application required for the exam.

Prospective nurses can prepare for the NCLEX-PN by engaging in regular study sessions, focusing on core areas such as pharmacology, patient care, and the nursing process. Active learning strategies, including practice questions and simulation exercises, can reinforce understanding and application of concepts. For example, reviewing the steps to assess a patient undergoing a blood transfusion and selecting the appropriate medication can underscore the interplay between assessment and intervention.

Preparation also involves familiarizing oneself with the exam format, managing time effectively, and employing relaxation techniques to reduce anxiety. Resources like NCLEX-style practice tests and study guides are vital in helping candidates build confidence and competency. Moreover, understanding the rationale behind correct and incorrect answer choices can enhance one's ability to think critically in real-world nursing scenarios.