A client is prescribed 100 mL of 3% normal saline solution received 1,000 ml of 3% normal saline. Which is the priority assessment for this client?
1. Skin integrity
2. Blood pressure
3. Capillary refill
4. Coagulation profile
Correct Answer: 2
Rationale 1: The nurse can assess for edema in this client, but the priority is to check the client's volume status by monitoring blood pressure.
Rationale 2: Overtreatment with hypertonic crystalloids such as 3% normal saline can lead to excessive expansion of the intravascular compartment, fluid overload, and hypertension.
Rationale 3: Capillary refill will not give the nurse as much information about volume status as will the client's blood pressure.
Rationale 4: This client's coagulation profile does not need to be monitored.
Global Rationale: Overtreatment with hypertonic crystalloids such as 3% normal saline can lead to excessive expansion of the intravascular compartment, fluid overload, and hypertension. The nurse can assess for edema in this client, but the priority is to check the client's volume status by monitoring blood pressure. Capillary refill will not give the nurse as much information about volume status as will the client's blood pressure. This client's coagulation profile does not need to be monitored.
You might also like to view...
Assistive devices such as canes, crutches, and walkers are used for people who need to limit weight-bearing on joints. The statement by the nurse that best illustrates an understanding of appropriate use of these devices is:
1. "Canes provide minimal support and balance and are carried on the unaffected side." 2. "When using a cane, slide it as you go to decrease the arm strain." 3. "A three-point gait is used when walking with a walker." 4. "When using crutches, the unaffected leg goes down the steps first."
When the urinary bladder is removed, a new pathway is needed for urine to exit the body. The new pathway is called a:
a. Urinary diversion b. Bladder diversion c. Renal pathway d. Renal tubule
_____ are medications to promote peristalsis
Fill in the blank(s) with the appropriate word(s).
Drugs are mainly eliminated from the body by ________.
A. enterohepatic recycling B. regurgitation C. sweating D. renal excretion