Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Rationale for Correct Choices • Acute kidney injury: The client gained 5 lb (2.3 kg) in 3 days with marked edema and minimal urine output, indicating fluid retention due to impaired renal perfusion after hypovolemic shock. The kidneys may be unable to excrete excess fluids effectively. • Measure electrolyte levels: Electrolyte imbalances (especially potassium and sodium) commonly occur with acute kidney injury, requiring frequent monitoring to guide fluid and medication management. • Assess lung sounds: Fluid overload may cause pulmonary congestion; auscultating lung fields helps detect early signs of crackles or respiratory distress indicating worsening fluid retention. • Daily weight: Tracking daily weights accurately reflects fluid gain or loss and helps evaluate the effectiveness of treatment in managing volume overload. • Electrocardiogram: Abnormal potassium levels due to impaired renal excretion can cause cardiac arrhythmias, making continuous ECG monitoring essential for safety. Rationale for Incorrect Choices • Hypovolemia: The client is fluid overloaded, not depleted, evidenced by edema, weight gain, and no IV fluids administered overnight. Hypovolemia would present with dry mucous membranes, hypotension, and tachycardia instead. • Hemorrhage: There is no surgical drainage or external bleeding; the dressing is intact, and hemoglobin monitoring alone wouldn’t explain the generalized edema or weight gain. • Septic shock: The client’s temperature, heart rate, and blood pressure are stable, with no signs of infection or inflammatory response suggesting sepsis. • Hold pressure on the surgical site: There is no active bleeding or wound oozing; applying pressure is unnecessary and unrelated to her current issue. • Give 1,000 mL of isotonic solution IV: Additional fluids would worsen her edema and fluid overload, further stressing compromised renal function. • Alert the rapid response team: The client is hemodynamically stable with normal vital signs, so this escalation is unwarranted at this time. • Hemoglobin: While it can detect anemia from blood loss, hemoglobin does not monitor renal function or fluid balance progression. • Capillary refill: This assesses peripheral perfusion and is not a reliable indicator of fluid overload or renal function status. • Surgical site drainage: The dressing is intact with no drainage, making it a low-priority parameter for monitoring renal progress.