The patient is receiving human serum albumin (Albuminar) as treatment for shock. What is a priority assessment by the nurse?
1. Auscultate breath sounds for hyper-resonance.
2. Auscultate for an absence of breath sounds in the lower lobes.
3. Auscultate breath sounds for inspiratory stridor.
4. Auscultate breath sounds for crackles.
4
Rationale 1: Hyper-resonance is assessed by percussion, not auscultation.
Rationale 2: An absence of breath sounds is heard with a pneumothorax, not with pulmonary edema.
Rationale 3: Stridor is auscultated with airway obstruction, not pulmonary edema.
Rationale 4: Because human serum albumin (Albuminar) 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.
Global Rationale: Because human serum albumin (Albuminar) 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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