A nurse is caring for an 84-year-old male client in the medical unit.

The client was admitted from a provider’s office with complaints of fatigue, dizziness, and shortness of breath. The nurse reviews the client’s medical records to prepare the client’s plan of care.

Exhibits

The client demonstrates mild orthostatic hypotension, with a drop in blood pressure upon standing.

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.

Choice A rationale

Dextrose 5% in water is not recommended for initial fluid resuscitation in burn patients because it does not provide the necessary electrolytes to address the fluid shifts and electrolyte imbalances that occur after a burn injury.

Choice B rationale

0.45% sodium chloride is a hypotonic solution and is not suitable for initial fluid resuscitation in burn patients. It can lead to cellular swelling and does not adequately replace the lost extracellular fluid.

Choice C rationale

Dextrose 5% in 0.9% sodium chloride is not the preferred choice for initial fluid resuscitation in burn patients. While it provides both glucose and electrolytes, it is not as effective as Lactated Ringers in addressing the specific needs of burn patients.

Choice D rationale

Lactated Ringers is the recommended fluid for initial resuscitation in burn patients. It is an isotonic solution that helps to restore circulating volume, correct electrolyte imbalances, and prevent hypovolemic shock.

Choice A rationale

Loss of appetite is a common symptom of appendicitis due to the inflammation and irritation of the gastrointestinal tract. This symptom alone does not indicate an immediate need for intervention.

Choice B rationale

Nausea and vomiting are also common symptoms of appendicitis. The pain and inflammation can stimulate the vomiting center in the brain, leading to nausea. This symptom, while uncomfortable, does not require immediate intervention.

Choice C rationale

Pain that worsens with movement, such as positioning on the right side, is typical of appendicitis. This is due to the irritation of the peritoneum and the inflamed appendix. This symptom is expected and does not require immediate intervention.

Choice D rationale

The sudden disappearance of pain in a patient with appendicitis can indicate a rupture of the appendix. This is a medical emergency as it can lead to peritonitis, a severe and potentially life- threatening infection of the abdominal cavity. Immediate intervention is required to prevent complications.