A nurse is caring for a 40-year-old client in a transplant unit.

Exhibits

The nurse is reviewing the client's assessment to prepare the client's plan of care.

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.

Answer and Explanation

The Correct Answer is []

Potential Condition:

Hypovolemia: The client shows signs of hypovolemia such as a low blood pressure (94/56 mm Hg), a high heart rate (110/min), and a relatively high urine output (1500 mL in the last hour), which may indicate an over-diuresis or inadequate fluid replacement postoperatively.

Actions to Take:

Obtain prescription for IV bolus: Administering an IV fluid bolus can help restore intravascular volume, thereby increasing blood pressure and improving perfusion to vital organs.

Lower head of bed: This action helps to increase venous return to the heart, which can help improve cardiac output and blood pressure in a hypovolemic patient.

Parameters to Monitor:

Urinary output: This is a key indicator of kidney function and fluid status. Monitoring urine output will help determine if the client is adequately responding to fluid resuscitation and maintaining appropriate kidney function.

Blood pressure: Continuous blood pressure monitoring is essential to evaluate the effectiveness of interventions aimed at correcting hypovolemia and ensuring the client's hemodynamic stability.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","D"]

Explanation

A. In January, WBC count was 5,500/mm3. In February, it decreased to 4,500/mm3. A decrease in WBC count indicates worsening in the client's condition since they are prone to infections.
B. In January, platelet count was 150,000/mm3. In February, it decreased slightly to 140,000/mm3. The slight decrease in platelet count may not necessarily indicate improvement but is relatively stable.
C. In January, the client reported bleeding episodes from mouth ulcers. In February, the client reports no bleeding episodes. The absence of bleeding episodes indicates improvement in oral mucosal health and potential effectiveness of interventions.
D. In January, the oral mucosa was inflamed. In February, there is noted improvement with less inflammation. Improved oral health with reduced inflammation indicates a positive response to interventions and potentially better oral hygiene practices.
E. The client experienced weight loss of 1.5 kg (3.3 lb) from January to February. Weight loss may indicate ongoing challenges with nutrition despite efforts to increase food intake and manage symptoms.

A. Humidify the client's room. B. Clean dentures in a denture cup. C. Serve cooked fruit with meals. D. Replace the water in flower vases with fresh water daily

Correct Answer is C

Explanation

A. Humidifying the client's room helps to maintain adequate moisture levels in the air. However, it is not specifically related to low WBC counts.
B. Cleaning dentures in a denture cup and serving cooked fruit with meals are good practices for hygiene and dietary considerations but do not directly address infection control.
C. Serving cooked fruit with meals can help minimize the risk of foodborne illnesses.
D. Replacing the water in flower vases with fresh water daily is important for preventing bacterial growth but is not as directly beneficial for infection prevention in this context.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has cancer and is undergoing chemotherapy. Exhibits Which of the following assessments indicates an improvement in the client's condition? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

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Correct Answer is C

Explanation

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