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. Insertion of an arteriovenous graft is not directly related to treating acute rejection but may be necessary if dialysis is needed.
B. Testing for HLA match is done before transplantation, not typically after acute rejection occurs.
C. Placement on the transplant waiting list is for patients who do not have a current functioning transplant.
D. Mycophenolate is an immunosuppressive medication commonly used to prevent or treat rejection in transplant patients.
Correct Answer is C
Explanation
A. Pediculicide lotions are used to treat lice, not ticks. They are not effective or appropriate for tick removal.
B. Twisting a tick during removal can cause the mouthparts to break off and remain embedded in the skin, increasing the risk of infection.
C. Grasping the tick as close to the skin as possible with fine-tipped tweezers allows for complete removal without squeezing the tick's body.
D. Using a hot ember or match tip can cause the tick to regurgitate into the skin, increasing the risk of disease transmission.
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