A client who had gastric bypass surgery 3 days ago is admitted to the intensive care unit (ICU) with shortness of breath and chest pain. The client has a 100% nonrebreather mask with an oxygen saturation of 88%. Which intervention should the nurse implement?

Prepare for oral intubation.

Apply leg compression hose.

Maintain head of bed at 45°.

Administer an anticoagulant.

Answer and Explanation

The Correct Answer is A

A. Prepare for oral intubation. The client is in severe respiratory distress with oxygen saturation at 88% despite receiving 100% oxygen via a nonrebreather mask. This suggests respiratory failure, likely due to a pulmonary embolism (PE), a known complication following bariatric surgery. Immediate intubation and mechanical ventilation are necessary to prevent further hypoxia and respiratory collapse.
B. Apply leg compression hose. While deep vein thrombosis (DVT) prophylaxis is essential for postoperative bariatric patients, it is not the priority in an acute emergency. Compression devices help prevent clots but do not treat an existing life-threatening pulmonary embolism.
C. Maintain head of bed at 45°. Elevating the head of the bed can help with breathing, but it will not significantly improve oxygenation in a client already failing on 100% oxygen. The priority is to secure the airway with intubation to provide controlled ventilation.
D. Administer an anticoagulant. Anticoagulation is a key treatment for pulmonary embolism, but it does not immediately improve oxygenation or stabilize respiratory function. In a hemodynamically unstable client with severe hypoxia, securing the airway takes priority before initiating anticoagulation therapy.

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Correct Answer is C

Explanation

A. Narrowed pulse pressure, presence of 3+ femoral pulses, apneic episodes. Narrowed pulse pressure is consistent with hypovolemic shock, but 3+ femoral pulses are not expected, as shock leads to weak, thready pulses due to reduced perfusion. Apneic episodes typically occur in the late stages of shock, not in the early or progressive stages.
B. Widening pulse pressure, muffled heart sounds, presence of atrial gallop. A widening pulse pressure and muffled heart sounds are more indicative of cardiac tamponade, not hypovolemic shock. Hypovolemic shock is characterized by a narrowing pulse pressure due to a drop in systolic blood pressure while diastolic pressure remains relatively stable.
C. Increased heart rate, lowered systolic reading, peripheral extremity mottling. Tachycardia is an early compensatory response to hypovolemia as the body attempts to maintain cardiac output. As shock progresses, systolic blood pressure drops due to inadequate circulating volume. Peripheral extremity mottling occurs as the body shunts blood to vital organs, reducing perfusion to the skin. These signs are characteristic of progressive hypovolemic shock.
D. Irregular heart rate, elevated diastolic reading, increased respiratory rate. An irregular heart rate is not a primary indicator of hypovolemic shock. While respiratory rate increases in response to decreased oxygen delivery, an elevated diastolic reading is uncommon, as diastolic pressure tends to stay stable or decrease slightly with ongoing hypovolemia.

A. Administer a PRN bolus normal saline. B. Obtain a blood specimen for hematocrit. C. Measure strict hourly urinary output. D. Switch oxygen delivery to a face mask.

Correct Answer is A

Explanation

A. Administer a PRN bolus normal saline. The client is exhibiting signs of hypovolemic shock, including tachycardia (HR 110 bpm), tachypnea (RR 24), and hypotension (BP 80/50 mmHg) following massive gastrointestinal bleeding and multiple blood transfusions. Immediate fluid resuscitation with a normal saline bolus is the priority to restore intravascular volume, maintain perfusion, and prevent further deterioration.
B. Obtain a blood specimen for hematocrit. While monitoring hematocrit is important to assess ongoing blood loss, it does not take priority over treating the client’s current hypovolemia. A delay in resuscitation could worsen hypotension, decrease organ perfusion, and lead to shock.
C. Measure strict hourly urinary output. Monitoring urine output is important in assessing renal perfusion and fluid balance, but the client’s immediate need is volume replacement. If fluid resuscitation is delayed, renal perfusion could worsen, leading to acute kidney injury.
D. Switch oxygen delivery to a face mask. The client’s oxygen saturation is 94% on 4 L/min nasal cannula, indicating adequate oxygenation at this time. Increasing oxygen delivery is not immediately necessary compared to fluid resuscitation. However, if the client’s condition worsens, oxygen therapy adjustments may be needed.

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A client who had gastric bypass surgery 3 days ago is admitted to the intensive care unit (ICU) with shortness of breath and chest pain. The client has a 100% nonrebreather mask with an oxygen saturation of 88%. Which intervention should the nurse implement?

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