A nurse is caring for an 84-year-old male client in the medical unit.

The client was admitted from a provider’s office with complaints of fatigue, dizziness, and shortness of breath. The nurse reviews the client’s medical records to prepare the client’s plan of care.

Exhibits

The client demonstrates mild orthostatic hypotension, with a drop in blood pressure upon standing.

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.

Choice A rationale

Lithotripsy, which uses shock waves to break up stones, is not part of an oral cholangiogram. An oral cholangiogram involves the use of a contrast dye to visualize the gallbladder and bile ducts on X-ray.

Choice B rationale

An endoscopic procedure, such as an endoscopic retrograde cholangiopancreatography (ERCP), involves inserting a camera down the throat. However, an oral cholangiogram is a non- invasive imaging test that uses contrast dye.

Choice C rationale

Correct. An oral cholangiogram involves the ingestion of a contrast dye that helps visualize the gallbladder and bile ducts on X-ray.

Choice D rationale

Medications to dissolve gallstones are not used in an oral cholangiogram. This procedure is purely diagnostic and involves the use of contrast dye to visualize the gallbladder and bile ducts.

Choice A rationale

While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.

Choice B rationale

Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.

Choice C rationale

Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.

Choice D rationale

Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.