A nurse is caring for a 40-year-old client in a transplant unit.
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Full body alopecia is a common side effect of chemotherapy but not directly related to myelosuppression.
B. Diarrhea and dehydration can occur with certain chemotherapeutic agents but are not specific to myelosuppression.
C. Anorexia and malnutrition are common during chemotherapy but are not specific to myelosuppression.
D. Myelosuppression can lead to decreased platelets and clotting factors, increasing the risk of bleeding from the gums and other sites.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}
Explanation
- This prescription helps maintain oral hygiene and comfort, which is important during chemotherapy to prevent and manage mucositis.
- Routine daily temperature checks may not be necessary unless there are specific concerns about infection or fever.
- Placing the client in a private room can reduce the risk of infection, which is crucial due to the client's immunocompromised state from chemotherapy.
- Unless there is a specific medical indication (e.g., urinary retention), inserting an indwelling urinary catheter increases the risk of infection, which should be minimized in an immunocompromised client.
- Droplet precautions are typically used for respiratory infections transmitted by large droplets. Lung cancer itself does not typically require droplet precautions unless there is an active respiratory infection.
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