The patient receives normal serum albumin. What are the priority assessments by the nurse?
1. Blood pressure and urinary output
2. Urinary output and pupil response
3. Blood pressure and level of pain
4. Urinary output and nausea or vomiting
1
Rationale 1: During fluid replacement therapy, the nurse must assess for fluid volume deficit and fluid volume excess. This is commonly done by assessment of blood pressure and urinary output.
Rationale 2: Pupil response is not a priority assessment.
Rationale 3: Level of pain is not a priority assessment.
Rationale 4: Nausea or vomiting is not the priority assessment.
Global Rationale: During fluid replacement therapy, the nurse must assess for fluid volume deficit and fluid volume excess. This is commonly done by assessment of blood pressure and urinary output. Level of pain is not a priority assessment. Pupil response is not a priority assessment. Nausea or vomiting is not the priority assessment.
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