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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 ["31.5"]

Explanation

Anterior= 18% (trunk) + 4.5 % (upper limb) +2.25% (forearm) =24.75%

Posterior= 4.5% (upper limb) +2.25% (forearm)= 6.75%

Total TBSA= 31.5%

Correct Answer is B

Explanation

A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not an escharotomy.

B. "Large incisions will be made in the eschar to improve circulation." An escharotomy involves making large incisions through the eschar (the tough, leathery scab or crust that forms over a severely burned area) to relieve pressure and improve blood flow to the affected area. This procedure is often necessary to prevent complications such as compartment syndrome and to enhance circulation in burn patients.

C. "The procedure involves placing the client into a shower and removing the dead tissue.": This describes debridement, not an escharotomy.

D. "Dead tissue will be non-surgically removed.": Non-surgical removal of dead tissue is debridement, not an escharotomy, which is a surgical procedure.

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