The nurse is planning care for a client in shock who is prescribed human serum albumin. Which of the following should the nurse include in this client's plan of care?
1. Auscultate for an absence of breath sounds in the lower lobes
2. Auscultate breath sounds for hyper-resonance
3. Auscultate breath sounds for crackles
4. Auscultate breath sounds for inspiratory stridor
3. Auscultate breath sounds for crackles
Rationale:
Because human serum albumin pulls fluid into the vascular space, circulatory overload is a serious complication. The nurse must monitor breath sounds; crackles will be heard with pulmonary congestion. An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema. Hyper-resonance is assessed by percussion, not auscultation. Stridor is auscultated with airway obstruction, not pulmonary edema.
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