A nurse is caring for a 40-year-old client in a transplant unit.
The nurse is reviewing the client's assessment to prepare the client's plan of care.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition:
Hypovolemia: The client shows signs of hypovolemia such as a low blood pressure (94/56 mm Hg), a high heart rate (110/min), and a relatively high urine output (1500 mL in the last hour), which may indicate an over-diuresis or inadequate fluid replacement postoperatively.
Actions to Take:
Obtain prescription for IV bolus: Administering an IV fluid bolus can help restore intravascular volume, thereby increasing blood pressure and improving perfusion to vital organs.
Lower head of bed: This action helps to increase venous return to the heart, which can help improve cardiac output and blood pressure in a hypovolemic patient.
Parameters to Monitor:
Urinary output: This is a key indicator of kidney function and fluid status. Monitoring urine output will help determine if the client is adequately responding to fluid resuscitation and maintaining appropriate kidney function.
Blood pressure: Continuous blood pressure monitoring is essential to evaluate the effectiveness of interventions aimed at correcting hypovolemia and ensuring the client's hemodynamic stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Reviewing the client's medical record is important for understanding their health status but is not directly related to investigating an injury claim at the workplace.
B. Reviewing the workplace procedures and protocols manual is crucial to understanding the standards and practices relevant to the injury claim.
C. The Occupational Safety and Health Act provides guidelines and regulations for workplace safety but does not provide specific details about individual injury claims.
D. The client's attendance record at health and safety seminars may be informative but is less directly relevant to investigating the injury claim compared to reviewing workplace protocols.
Correct Answer is C
Explanation
A. This client has respiratory distress but is conscious and stable, requiring urgent but not immediate attention compared to other critical conditions.
B. This client has a dislocated shoulder, which is painful and needs attention but is not life-threatening compared to other conditions.
C. This client is unconscious with a sucking chest wound and high respiratory rate, indicating severe respiratory compromise and needing immediate intervention to prevent further deterioration.
D. This client is also unconscious with no respirations despite attempted airway management, indicating a need for immediate resuscitative efforts, potentially including CPR.
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