The nurse is caring for a patient who is very dehydrated. Which ...

[SO00]

The nurse is caring for a patient who is very dehydrated. Which goal best indicates that the nursing diagnosis of Deficient fluid volume has been corrected and that the patient's fluid balance has been restored?
 
  a. The patient had 1300 mL of light yellow urine in the last 24 hours.
  b. The patient's lung sounds are clear bilaterally.
  c. The patient has no jugular venous distention.
  d. The patient verbalizes need for adequate daily fluid intake.

Question 2

The nurse is caring for a patient who is receiving a blood transfusion. One hour into the transfusion, the patient's blood pressure decreases significantly and the patient complains of a severe headache. What is the priority action of the nurse?
 
  a. Check the patient's temperature and administer acetaminophen (Tylenol) if higher than 101  F.
  b. Recheck the patient's blood pressure in 15 minutes after administering pain medication.
  c. Stop the blood transfusion and administer 0.9 normal saline through new IV tubing.
  d. Double-check that the transfusion blood type is an exact match to the patient.

[kkenney]

Answer to Question 1

ANS: A
The goal that best indicates that the patient's dehydration has been corrected is output of 1300 mL of clear yellow urine in the last 24 hours. Dark concentrated urine is a symptom of dehydration. Jugular venous distention and presence of crackles in the lungs are both indicative of fluid volume overload.

Answer to Question 2

ANS: C
A significant drop in blood pressure and a severe headache are signs that the patient may be experiencing a transfusion reaction. The transfusion should be stopped and 0.9 normal saline should be administered through new IV tubing to prevent infusion of additional blood through the tubing used for the transfusion. The physician should be notified immediately to evaluate the patient. Ensuring that the transfusion blood type is an exact match to the patient is done before the transfusion is begun.