A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Choice A: Evaluating chest expansion is the first action that the nurse should take, because it assesses the client's respiratory status and potential for pneumothorax, which is a life-threatening condition that can result from chest trauma. The nurse should compare the movement of both sides of the chest and listen for breath sounds.

Choice B: Checking pupillary response to light is an important action, but not the first one, because it assesses the client's neurological status and potential for brain injury. The nurse should observe the size, shape, and symmetry of the pupils and their reaction to light.

Choice C: Checking the client's response to questions about place and time is another important action, but not the first one, because it assesses the client's level of consciousness and orientation. The nurse should ask the client simple questions such as their name, date, and location.

Choice D: Assessing the capillary refill is a less important action, and not the first one, because it assesses the client's peripheral circulation and tissue perfusion. The nurse should press on the client's nail beds or fingertips and observe how quickly the color returns.

Choice A Reason: Dextran 70 is not a medication that the nurse should plan to administer for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Dextran 70 is a plasma expander that increases the blood volume and viscosity, which can worsen the intracranial pressure by increasing the cerebral blood flow and edema.

Choice B Reason: Hydroxyethyl starch is not a medication that the nurse should plan to administer for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Hydroxyethyl starch is another plasma expander that has similar effects as dextran 70, and can also increase the risk of coagulopathy and renal failure.

Choice C Reason: Albumin 25% is not a medication that the nurse should plan to administer for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Albumin 25% is a colloid solution that increases the oncotic pressure and draws fluid from the interstitial space into the intravascular space, which can also worsen the intracranial pressure by increasing the cerebral blood flow and edema.

Choice D Reason: Mannitol 25% is a medication that the nurse should plan to administer for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Mannitol 25% is an osmotic diuretic that reduces the intracranial pressure by creating an osmotic gradient and drawing fluid from the brain tissue into the blood vessels, which can then be excreted by the kidneys. The nurse should monitor the urine output, serum osmolality, and electrolytes when administering mannitol 25%.