Question

A nurse on a rehabilitation unit is caring for a client who was admitted 3 days ago. Upon review of the client's medical record, which of the following actions should the nurse take?

1) Monitor the client's blood pressure closely
2) Administer a diuretic to reduce peripheral edema
3) Increase the client's glucose intake
4) Refer the client to a respiratory therapist

Answer 1

The nurse should monitor the client's blood pressure closely.

Step-by-step explanation:

Upon review of the client's medical record, the nurse should monitor the client's blood pressure closely. Monitoring the blood pressure will help the nurse assess the client's cardiovascular stability and detect any changes that may require further intervention. Administering a diuretic to reduce peripheral edema may be appropriate if the client has signs of fluid overload, but this cannot be concluded without further assessment. Increasing the client's glucose intake or referring the client to a respiratory therapist are not indicated based on the information given.