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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 C

Explanation

A. Packed RBCs - These are used to treat anemia or significant blood loss but do not address the clotting deficiency in hemophilia.

B. Fresh frozen plasma - This contains all clotting factors, but in hemophilia A, specifically replacing factor VIII is more effective and targeted.

C. Recombinant - Recombinant factor VIII is a synthetic form of the clotting factor that patients with hemophilia A are deficient in. It is used to increase factor VIII levels before procedures to prevent excessive bleeding.

D. Prophylactic antibiotics - These are used to prevent infection but do not help in managing the bleeding risks associated with hemophilia.

Correct Answer is A

Explanation

A. Obtain a venous duplex ultrasound. These symptoms suggest a deep vein thrombosis (DVT), and a venous duplex ultrasound is the standard diagnostic test to confirm the presence of a thrombus in the veins.

B. Obtain impedance plethysmography: This is less commonly used than ultrasound and may not provide as clear a diagnosis.

C. Monitor Homan's sign: Homan's sign is no longer considered reliable or safe for diagnosing DVT due to the risk of dislodging a thrombus.

D. Apply cold therapy to the affected leg: Cold therapy is not appropriate for DVT as it does not treat the underlying issue and could potentially cause vasoconstriction, worsening the condition.

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