A client on the cardiac telemetry unit unexpectedly begins manifesting ventricular fibrillation and the advanced cardiac life support (ACLS) team defibrillates the client, restoring a normal sinus rhythm. Later in the day, a family member questions why the code was called, telling the nurse that the client has a living will. How should the nurse respond?

A. Every 5 minutes for 30 minutes is crucial after paracentesis to closely monitor for signs of hypovolemia, such as a sudden drop in blood pressure. After this initial intensive monitoring period, the frequency can be reduced to every 4 hours to assess for any delayed effects or complications.

B. Every 5 minutes for one hour is a shorter duration of monitoring compared to option A and

may not provide adequate time to detect and respond to any significant changes in blood pressure that could occur after paracentesis, especially considering the volume of fluid removed.

C. Every 15 minutes for one hour, then every 1 hour for 2 hours provides frequent monitoring

initially, but the interval between assessments is too long after the first hour, potentially missing early signs of complications such as hypovolemia.

D. Every 1 hour for 2 hours does not provide sufficient frequency of monitoring, especially during the critical immediate post-paracentesis period when rapid changes in blood pressure can occur. This schedule may delay the detection and management of complications.

A. Administer oxygen 5 L/minute via simple face mask: Oxygen administration is a priority intervention to improve oxygenation and address the client's low oxygen saturation of 82%.
Hypoxemia can lead to tissue hypoxia and further compromise the client's condition. Therefore, administering oxygen should be the first action taken to ensure an adequate oxygen supply to vital organs.
B. Bacitracin applied topically to lacerations every 12 hours: While wound care is important, administering oxygen and establishing IV access take precedence over topical
treatment. Oxygenation and fluid resuscitation are critical in the immediate management of a trauma patient to ensure adequate tissue perfusion and oxygen delivery.

C. Place 2 large bore peripheral IV's: Establishing IV access is essential for administering medications and fluids rapidly. This is particularly important in this scenario where the client may require immediate fluid resuscitation due to hypotension (blood pressure of 83/41 mm Hg).
Large bore IV access allows for rapid infusion of fluids and medications to stabilize the client's hemodynamic status.

D. X-ray of the right arm and cervical spine: While diagnostic imaging is important for assessing injuries, it is not as urgent as administering oxygen and establishing IV access. Oxygenation and fluid resuscitation are higher priorities to stabilize the client's condition before proceeding with diagnostic tests.

E. Computed tomography scan of the brain: While a CT scan of the brain is essential for assessing potential head injuries, the immediate focus should be on stabilizing the client's oxygenation and hemodynamic status. Administering oxygen and fluids take precedence over diagnostic imaging to address the client's hypoxemia and hypotension.

F. Vital signs every 1 hour: Monitoring vital signs is important for ongoing assessment, but it is not as urgent as administering oxygen and fluids. Vital signs should be monitored closely, but immediate interventions to address hypoxemia and hypovolemia are critical to stabilize the client's condition.

G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once: The client's hypotension (blood pressure of 83/41 mm Hg) indicates hypovolemia and the need for fluid resuscitation. Administering a bolus of intravenous fluids (1 Liter bolus of 0.9% sodium chloride solution) is essential to address hypovolemia and improve perfusion to vital organs. This intervention helps stabilize the client's blood pressure and prevent further deterioration of her condition.