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 C
Explanation
A. Applying a warm pack can increase the absorption of venom and worsen symptoms.
B. Applying a tourniquet can restrict blood flow and worsen local effects of the venom.
C. Removing the stinger by scraping it off with a knife blade is the correct method to prevent further venom injection.
D. Sucking the wound can introduce infection and is not recommended.
Correct Answer is C
Explanation
A. Mental status assessment involves evaluating a client's cognitive and emotional function.
B. Nutritional assessment involves evaluating a client's dietary intake and nutritional status.
C. An environmental health assessment involves assessing exposure to environmental hazards such as chemicals and pollutants.
D. Faith-based assessment involves exploring a client's religious or spiritual beliefs and practices.
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