A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate?

A reason:

Decreased heart rate is not a manifestation of hypovolemia. In fact, hypovolemia typically causes an increased heart rate (tachycardia) as the body attempts to compensate for the reduced blood volume.

B reason:

Increased blood pressure is not a characteristic of hypovolemia. Hypovolemia usually results in decreased blood pressure (hypotension) due to the reduced volume of blood circulating in the body.

C reason:

A weak pulse is a common manifestation of hypovolemia. Due to the reduced blood volume, the heart may not be able to generate a strong pulse, resulting in a weak and thready pulse.

D reason:

Dyspnea, or difficulty breathing, can be associated with hypovolemia but it is not as direct a manifestation as a weak pulse. It may occur due to inadequate oxygen delivery to tissues or related conditions, but the primary signs of hypovolemia are related to blood pressure and pulse.

A reason:

Notifying the surgeon that the client wishes to withdraw informed consent for the procedure is correct. The client's autonomy and right to refuse treatment must be respected, and the surgeon should be informed to discuss the client's concerns and possible alternatives.

B reason:

Proceeding with preparation for the surgical procedure without addressing the client's withdrawal of consent violates ethical and legal standards. The client's decision must be honored.

C reason:

Reminding the client that a signed informed consent form is legally binding is incorrect. Informed consent can be withdrawn at any time, and the client's right to change their mind must be respected.

D reason:

Informing the surgical team to cancel the surgery is not the nurse's decision alone. The nurse should first notify the surgeon to ensure that all necessary discussions and documentation occur.