The nurse is administering albumin 5% to a client in shock. Which nursing action is appropriate when assessing this client?
A) Auscultate breath sounds for inspiratory stridor.
B) Auscultate breath sounds for crackles.
C) Auscultate breath sounds for hyperresonance.
D) Auscultate for an absence of breath sounds in the lower lobes.
Answer: B
Because albumin 5% is a volume expander and 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. Hyperresonance is assessed by percussion, not auscultation. Stridor is auscultated with airway obstruction, not pulmonary edema.
You might also like to view...
After undergoing dural puncture while receiving epidural pain medication, a patient reports a headache. Which action can help alleviate the patient's pain?
a. Encourage the client to ambulate to promote flow of spinal fluid. b. Offer caffeinated beverages to constrict blood vessels in his head. c. Encourage coughing and deep breathing to increase CSF pressure. d. Restrict oral fluid intake to prevent excess spinal pressure.
The client has undergone cryosurgery for stage IA cervical cancer. Which precaution or action should the nurse teach this client?
A. "Use sanitary napkins rather than tampons to manage the watery discharge for the next several weeks." B. "Avoid becoming pregnant for the next 12 months or until three successive Pap tests remain negative." C. "If you should become pregnant, you will be at increased risk for preterm labor." D. "Your next menstrual cycle will be delayed because of this procedure."
The nurse is caring for a client who is experiencing metabolic alkalosis. The nurse plans to protect the client's safety, knowing the risks of this imbalance, by carefully implementing which of the following prescribed precautions?
1. Contact isolation 2. Seizure precautions 3. Bleeding precautions 4. Neutropenic precautions
Which of the following health risks is one of the foremost predictors of health?
a. Biologic b. Economic c. Lifestyle d. Social