A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Choice A Reason: This is incorrect. Flushing of the skin is not a sign of hypovolemic shock, but rather of vasodilation or fever. Hypovolemic shock causes vasoconstriction and pale, cool, clammy skin.

Choice B Reason: This is correct. Oliguria is a decreased urine output that indicates reduced renal perfusion due to hypovolemia. The normal urine output for an adult is 0.5 to 1 mL/kg/hr.

Choice C Reason: This is incorrect. Hypertension is not a sign of hypovolemic shock, but rather of increased vascular resistance or fluid overload. Hypovolemic shock causes hypotension due to decreased blood volume and cardiac output.

Choice D Reason: This is incorrect. Bradypnea is a slow respiratory rate that indicates respiratory depression or fatigue. Hypovolemic shock causes tachypnea due to hypoxia and increased metabolic demand.

The correct answer is: d. Brachial pulse in the right arm.

Choice A reason: Palpating the radial pulse in the right arm is not the most appropriate choice following a cardiac catheterization with a left antecubital insertion site. While it is contralateral to the insertion site, the brachial pulse is preferred over the radial pulse for assessing circulation in the arm, as it is more proximal and can provide a better indication of arterial flow from the catheterization site.

Choice B reason: The radial pulse in the left arm is the correct choice because it evaluates distal circulation in the affected limb. Since the catheterization was performed through the left antecubital fossa, it is crucial to monitor blood flow further down in the arm. Palpating the radial pulse helps detect early signs of compromised perfusion, such as diminished pulse strength. Evidence-based guidelines from clinical sources highlight the importance of distal pulse assessment post-catheterization.

Choice C reason: Palpating the brachial pulse in the left arm is also not recommended. Since the catheterization was performed on the left side, there is a risk of arterial occlusion or spasm, which could affect the accuracy of the pulse assessment in the left arm.

Choice D reason: The brachial pulse in the right arm does not provide relevant information about the left arm’s vascular status post-catheterization. Since the right arm was not affected by the procedure, its pulse does not indicate possible complications in the left arm. Clinical assessment should focus on detecting perfusion issues in the limb where the catheter was inserted. Best practices recommend prioritizing the evaluation of circulation in the affected extremity.