The nurse is administering albumin 5 to a client in shock. Which ...

[pragya sharda]

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.

Question 2

The nurse has just completed the assessment of a client admitted with a gunshot wound to the femoral artery. Which is the priority nursing diagnosis for this client?
 
  A) Deficient Fluid Volume
  B) Ineffective Coping
  C) Ineffective Airway Clearance
  D) Decreased Cardiac Output

[cuttiesgirl16]

Answer to Question 1

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.

Answer to Question 2

Answer: D

The client sustained a gunshot wound to the femoral artery, which would lead to significant bleeding and the risk of hypovolemic shock. The nursing diagnosis that would be a priority for the client is Decreased Cardiac Output because of low blood volume. There is not enough information to determine whether the client has ineffective airway clearance. The client will most likely have deficient fluid volume; however, cardiac output is the first priority at this time. There is not enough information to determine whether the client is experiencing ineffective coping.