Choice A rationale

Given the client’s high blood pressure and complaint of a headache, it is important to continuously monitor the client’s cardiac status to detect any changes that may indicate worsening condition.

Choice B rationale

Placing an indwelling urinary catheter is not the immediate next step in this client’s care. While it may be necessary in some cases, it is not directly related to the client’s current symptoms.

Choice C rationale

Giving a fluid bolus is not the immediate next step in this client’s care. While it may be necessary in some cases, it is not directly related to the client’s current symptoms.

Choice D rationale

Drawing a basic metabolic panel (BMP) could be helpful in assessing the client’s overall health and kidney function, but it is not the immediate next step in this client’s care.

Choice A rationale
Heart rate is an important vital sign to monitor in patients, but it is not the primary outcome
data to prioritize when administering a 20% mannitol intravenous (IV) solution. Mannitol is a diuretic that works by increasing the amount of urine produced. Therefore, while heart rate can be affected by fluid balance changes, it is not the most directly relevant outcome to monitor in this context.
Choice B rationale
Ankle circumference could be an indicator of peripheral edema, which might suggest fluid
overload or poor kidney function. However, in the context of mannitol administration, which is a diuretic and would be expected to decrease fluid overload, ankle circumference is not the primary outcome to monitor.
Choice C rationale
Urinary output is the correct answer. Mannitol is an osmotic diuretic that increases urine
production. It is used to reduce intracranial and intraocular pressure by drawing water out of tissues and into the bloodstream, from where it can be excreted by the kidneys. Therefore, urinary output is the most direct measure of its effectiveness and is the key outcome that should be monitored.
Choice D rationale
Dietary intake is always important to monitor in patients, especially those receiving IV
therapy, as it can impact electrolyte balance and overall health status. However, it is not the primary outcome to monitor when administering mannitol.