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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","C","E"]

Explanation

A. D-dimer blood test - A D-dimer test measures clot breakdown products in the blood. Elevated levels suggest the presence of an abnormal blood clot, such as in PE, although it is not specific.

B. Complete blood count (CBC) - A CBC is not typically used to diagnose PE. It may be ordered to check for other conditions or as part of the overall health assessment, but it doesn't confirm PE.

C. CT scan - A CT pulmonary angiography is the gold standard for diagnosing PE. It provides detailed images of the blood vessels in the lungs.

D. Chest x-ray - A chest x-ray is not diagnostic for PE. It is often performed to rule out other causes of the client’s symptoms (e.g., pneumonia, pneumothorax) but does not confirm the presence of a pulmonary embolism.

E. Lung ventilation and perfusion scan (VQ scan)
A VQ scan is another diagnostic tool for PE, especially in clients who cannot tolerate contrast dye required for CT scans. It assesses the ventilation and perfusion of the lungs and identifies mismatches suggestive of PE.

Correct Answer is D

Explanation

A. Slurred speech - This is not a common symptom of iron deficiency anemia. It might suggest a neurological issue or other condition.

B. Confusion - While severe anemia might lead to confusion due to reduced oxygen delivery to the brain, it is not as common as fatigue and is usually seen in more advanced stages or in combination with other factors.

C. Pain - Pain is not a typical symptom of iron deficiency anemia unless it is related to other conditions like muscle fatigue from overall weakness.

D. Fatigue - Fatigue is a hallmark symptom of iron deficiency anemia due to the decreased ability of the blood to carry oxygen to tissues, leading to overall tiredness and lack of energy.

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