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A nurse is caring for a client in a medical-surgical unit.

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.


 

Answer and Explanation

The Correct Answer is []

Condition:

  • Transfusion-associated circulatory overload (TACO)

Actions the Nurse Should Take:

  1. Stop transfusion (D): This is crucial to prevent further fluid overload and worsening symptoms.
  2. Administer furosemide (C): Furosemide is a loop diuretic that can help remove excess fluid and alleviate symptoms of fluid overload.

Parameters to Monitor:

  1. Weight (B): Monitor weight to assess for fluid retention and overload.
  2. Respiratory rate (C): Monitor respiratory rate closely for signs of respiratory distress such as dyspnea and increased effort.


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Related Questions

Correct Answer is B

Explanation

Correct answer: B

A. Myopia - Myopia (near-sightedness) is a vision condition related to the shape of the eye and is not related to Meniere's disease or endolymph fluid accumulation.

B. Vertigo - Vertigo is a primary symptom of Meniere's disease and is caused by the excessive accumulation of endolymph fluid in the inner ear, which affects balance and spatial orientation.

C. Photophobia - Sensitivity to light is not a symptom of Meniere's disease; it is more commonly associated with migraines or eye conditions.

D. Presbycusis - Presbycusis is age-related hearing loss and is unrelated to the fluid balance issues seen in Meniere's disease.

Correct Answer is B

Explanation

A. Keep family members aware of his condition: While important, keeping family informed is not as directly impactful on the client’s emotional support as direct interaction with the client.

B. Talk with the client during wound care. Talking with the client during wound care can help to establish a trusting relationship, provide emotional support, and help the client cope with the pain and stress associated with burn treatment.

C. Rotate nursing staff so he can have varied interactions: Continuity of care is often more comforting to clients than having varied interactions.

D. Assign assistive personnel to keep his room neat and clean: This task is important for infection control but does not directly provide emotional support.

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