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

Quizplus · Accepted Answer

A) 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.
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.
C) 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.
D) 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.

The Nurse Is Administering Albumin 5% to a Client in Shock.Which