1704: Client brought to the ED by ambulance because of persistent dizziness that is worse when she changes positions. On assessment, the client is alert and oriented. She reports persistent dizziness and fatigue. Lung sounds are diminished bilaterally. Peripheral pulses are 3+. Anasarca noted. Bowel sounds are normoactive in all four quadrants. The client reports intermittent nausea. Skin is warm to touch. The client denied any pain. Vital signs: P 101, RR 20, BP 90/62, pulse oximetry reading 95% on room air. The client has a medical history of end-stage liver cirrhosis and hyperlipidemia.
The nurse plans care for this client.
➢ For each potential nursing intervention, click to specify whether the intervention is indicated or not indicated for the care of the client.
Note: Each row must have 1 response option selected.
- A. Place the client in Trendelenburg position
- B. Insert a peripheral IV line with large-bore catheter
- C. Obtain a prescription to administer a bolus of hypotonic IV fluids
- D. Perform a 12-lead electrocardiogram (ECG)
- E. Obtain a prescription to administer intravenous albumin
- F. Obtain an order to insert a nasogastric tube (NGT)
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