A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?

Rationale:
A. Hypotension: Circulatory overload typically causes hypertension rather than hypotension due to increased blood volume and pressure. Hypotension would be more consistent with a different transfusion reaction such as anaphylaxis or septic shock.

B. Flattened jugular veins: Jugular vein distention, not flattening, is a classic sign of circulatory overload. Distended neck veins indicate elevated central venous pressure from fluid excess.

C. Lethargy: While lethargy may occur with various conditions, it is not a specific or early sign of circulatory overload. More immediate symptoms include respiratory distress and cardiovascular changes.

D. Bounding pulse: A bounding pulse is a key sign of circulatory overload, reflecting increased stroke volume and elevated intravascular volume. It often occurs alongside hypertension, dyspnea, and jugular vein distention, especially in older adults with compromised cardiac function.

Rationale:

A. Administer oxygen: The client is experiencing labored respirations and increasing distress. Although their oxygen saturation is currently within normal range, supplemental oxygen is a priority to support oxygenation during this acute episode, especially with signs of anxiety and shortness of breath.

B. Obtain prescription for amiodarone: Amiodarone is used for certain ventricular arrhythmias. The client’s heart rhythm is described as regular, though tachycardic, not indicating a need for amiodarone. This is not an immediate priority without evidence of a specific arrhythmia like ventricular tachycardia.

C. Place client in semi-Fowler's position: Elevating the head of the bed helps reduce the work of breathing and improves lung expansion. This position supports respiratory function, especially when the client is experiencing shortness of breath.

D. Monitor blood pressure every 30 minutes: Blood pressure monitoring is important, but this action is not immediate in the face of worsening symptoms. The client needs more urgent interventions first, including respiratory and cardiac stabilization.

E. Obtain prescription for a beta blocker: The client’s heart rate increased significantly to 170/min and they have a history of poorly controlled hypertension. A beta blocker may be needed to reduce sympathetic overactivity and heart rate, helping to lower blood pressure and myocardial oxygen demand.

F. Monitor for neurologic complications: With a blood pressure of 185/100 mmHg and a worsening severe headache, the client is at risk for neurologic complications such as hypertensive encephalopathy or stroke. Close neurologic monitoring is essential to detect early signs of deterioration.