A nurse is contributing to the plan of care for a client who had a craniotomy. Which of the following interventions should the nurse include in the plan?

a. Neck vein distention: Neck vein distention may indicate fluid overload, but it is not a direct measure of fluid losses.

b. Body weight: Monitoring body weight before and after hemodialysis provides a direct

measure of fluid losses. Hemodialysis removes excess fluid, and changes in body weight reflect fluid balance.

c. Abdominal girth: Abdominal girth may be affected by fluid accumulation but is not a direct measure of fluid losses during hemodialysis.

d. Blood pressure: While blood pressure may be influenced by fluid status, it is not a specific measure of fluid losses during hemodialysis. Body weight is a more direct indicator of fluid removal.

A. Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.

B. Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.

The priority is to determine the client's immediate physiological status.

C. Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting of

nausea and refusal of breakfast.

D. Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.