Four hours after rhinoplasty, a client is swallowing repeatedly. Which priority action should the practical nurse (PN) take?

Choice A reason: A respiratory rate of 28 breaths per minute indicates tachypnea, which can be a response to pain, anxiety, or hypovolemia. While it is important to monitor and manage respiratory status, this finding alone is not as critical as urine output when assessing the client's overall condition and fluid balance. Tachypnea should be reported, but it is not the most urgent parameter in this scenario.
Choice B reason: A blood pressure of 110/90 mm Hg is within a range that might be acceptable for some individuals, though the pulse pressure is narrow. In the context of a client receiving blood and fluid replacement, it is important to monitor blood pressure closely to ensure adequate perfusion. However, this reading does not immediately suggest a severe complication or shock, and other parameters might take precedence for immediate reporting.
Choice C reason: Urine output of 20 mL in the last hour is significantly low, indicating potential renal hypoperfusion or early signs of shock. Adequate urine output is a crucial indicator of renal perfusion and overall fluid status. Oliguria (reduced urine output) in this context suggests that the client's organs may not be receiving sufficient blood flow, which is a critical condition that requires prompt intervention. This finding should be reported immediately to the charge nurse to ensure timely and appropriate management.
Choice D reason: A pain score of 8 out of 10 indicates severe pain, which needs to be managed effectively to ensure the client's comfort and prevent further physiological stress. While addressing pain is important, it does not directly indicate a life-threatening condition compared to low urine output. Pain management should be part of the overall care plan, but reporting the critically low urine output takes priority in this situation.

Choice A reason: Placing the food and utensils in the client's left visual field and leaving him alone does not address the underlying issue of the visual field deficit. While it may temporarily solve the problem of the client eating only the food on the left side, it does not encourage the client to adapt to or compensate for the right homonymous hemianopsia. The goal of rehabilitation is to help the client develop strategies to manage their condition independently, and this approach does not foster such skills.
Choice B reason: Feeding the client foods that are on the right side of his visual field is not the most effective approach, as it does not promote the client's independence or help them adapt to their visual field deficit. While it ensures the client consumes the food on the right side, it does not teach the client to compensate for their hemianopsia, which is an essential aspect of their rehabilitation.
Choice C reason: Reminding the client to look all over the tray to view and eat all the foods provided is the best approach. This action helps the client become more aware of their visual field deficit and encourages them to develop the habit of scanning their environment. Teaching the client to consistently look around their entire visual field promotes independence and helps them adapt to daily activities despite their condition. This strategy supports the goal of rehabilitation, which is to enhance the client's ability to manage their visual impairment independently.
Choice D reason: Prompting the client to rotate his plate to see foods on the right side of the tray is a practical solution, but it does not address the broader need for the client to learn to scan their environment. While rotating the plate may temporarily help the client access the food on the right side, it does not encourage the development of compensatory strategies for the visual field deficit. Encouraging the client to look all over the tray is a more effective approach for long-term adaptation and independence.