A nurse is collecting data from a client who has Graves' disease. Which of the following images should the nurse identify as an indication that the client is experiencing exophthalmos?

 

A. Primary health problem: Including the primary diagnosis or health problem ensures the receiving ICU team understands the client’s current medical condition and the reason for transfer. This information guides immediate interventions and prioritization of care.

B. Admission vital signs from 1 week ago: Historical vital signs from admission are generally not relevant for transfer documentation unless they reflect a trend affecting current status. The focus should be on recent and current assessments that impact immediate care.

C. Number of family members who have visited: While family presence is important for psychosocial support, it does not directly influence the ICU care plan. This information is not essential in transfer documentation for clinical management.

D. Current medication prescriptions: Accurate documentation of all current medications is critical to ensure continuity of care and prevent errors in the ICU. This includes dosages, routes, and timing to avoid omissions, duplications, or interactions.

E. Scheduled times for dressing changes: Providing information about ongoing treatments, such as wound care schedules, ensures the ICU team can continue necessary interventions without delay. This supports continuity and safety of care during the transfer.

A. Potassium level: The potassium level of 3.2 mEq/L is below the normal range and indicates hypokalemia, which furosemide can worsen because it promotes potassium loss. Administering the medication now increases the risk of arrhythmias. Correcting the potassium imbalance is essential before giving a loop diuretic.

B. Client verbal report: The client reports diarrhea, dry mouth, and excessive thirst, which suggest ongoing fluid depletion. Giving furosemide in this state can lead to further intravascular volume loss and increase the risk of hypotension or renal impairment.

C. Blood pressure: The blood pressure of 122/68 mm Hg is stable and does not indicate hypotension or hemodynamic compromise. This value would not independently prevent the administration of furosemide, as diuretics can be safely given when blood pressure is within an acceptable range.

D. Prescription for digoxin: Furosemide-induced potassium loss raises the risk of digoxin toxicity, especially when the potassium level is already low. Hypokalemia sensitizes cardiac tissue to digoxin, increasing the chance of dangerous dysrhythmias. This combination requires correction of electrolytes before administering the diuretic.

E. BUN: The BUN of 19 mg/dL is within normal limits and does not indicate renal dysfunction or dehydration severe enough to contraindicate treatment. It provides no evidence of impaired renal clearance that would complicate furosemide use.