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

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:

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

Parameters to Monitor:

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

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Correct Answer is B

Explanation

A. Keep family members aware of his condition: While important, keeping family informed is not as directly impactful on the client’s emotional support as direct interaction with the client.

B. Talk with the client during wound care. Talking with the client during wound care can help to establish a trusting relationship, provide emotional support, and help the client cope with the pain and stress associated with burn treatment.

C. Rotate nursing staff so he can have varied interactions: Continuity of care is often more comforting to clients than having varied interactions.

D. Assign assistive personnel to keep his room neat and clean: This task is important for infection control but does not directly provide emotional support.

A. Consume foods high in potassium B. Avoid smoking tobacco products C. increase oral intake of water D. Limit alcohol to two drinks daily

Correct Answer is B

Explanation

A. Consume foods high in potassium: Potassium is important for ear health, but there is no direct evidence that high-potassium foods alone reduce the risk of hearing loss.

B. Avoid smoking tobacco products: Smoking is associated with an increased risk of hearing loss due to its negative effects on blood flow to the cochlea and the auditory nerve. Avoiding smoking can reduce the risk of hearing damage.

C. Increase oral intake of water: While staying hydrated is good for overall health, it does not specifically impact hearing loss risk.

D. Limit alcohol to two drinks daily: Excessive alcohol consumption can affect hearing, but moderation is not directly associated with preventing hearing loss as effectively as avoiding smoking.

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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