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A nurse is caring for a client in a medical-surgical unit.

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.


 

Answer and Explanation

The Correct Answer is []

Condition:

  • Transfusion-associated circulatory overload (TACO)

Actions the Nurse Should Take:

  1. Stop transfusion (D): This is crucial to prevent further fluid overload and worsening symptoms.
  2. Administer furosemide (C): Furosemide is a loop diuretic that can help remove excess fluid and alleviate symptoms of fluid overload.

Parameters to Monitor:

  1. Weight (B): Monitor weight to assess for fluid retention and overload.
  2. Respiratory rate (C): Monitor respiratory rate closely for signs of respiratory distress such as dyspnea and increased effort.


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Related Questions

Correct Answer is A

Explanation

A. Heart rate: Adequate fluid resuscitation in burn patients helps to restore intravascular volume, improving circulation and perfusion. A decrease in heart rate indicates improved cardiac output and reduced compensatory tachycardia, suggesting adequate fluid replacement.

B. Weight: Fluid replacement can lead to an increase in weight due to the volume of fluids administered, not a decrease.

C. Urine output: Adequate fluid resuscitation typically increases urine output as renal perfusion improves.

D. Blood Pressure (BP): While BP can stabilize with adequate fluid resuscitation, it is not as direct an indicator as a decrease in heart rate in reflecting improved perfusion and hydration status.

Correct Answer is C

Explanation

A. Hemoglobin level:While knowing the hemoglobin level helps determine the need for the transfusion, it is generally assessed and ordered by the provider before the transfusion is prescribed. It is important information but not the most immediate data required directly before administering the PRBCs.

B. Fluid intake:Monitoring fluid balance is important, especially in clients at risk for fluid overload, but it is not as immediately critical as temperature in detecting potential reactions to the transfusion.

C. Temperature:A baseline temperature is crucial to monitor for febrile reactions during the transfusion. Any significant rise in temperature can signal a transfusion reaction, which requires immediate intervention.

D. Skin color:Skin color can provide information on overall oxygenation and perfusion but is not as specific or immediately useful as temperature for monitoring for transfusion reactions.

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