Temperature: 96.9 F (36.1 C) measured via internal probe via urinary catheter.
Heart rate: 128 beats/minute, sinus tachycardia (ST). Respirations: 14 breaths/minute.
Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg. Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2). IV fluid bolus given as prescribed.
The client’s surgical dressing is clean and dry.
Ecchymosis is noted on the abdomen around the dressing.
The client has a peripheral intravenous (PIV) line in the right forearm and one in the left hand.
The client also has a right subclavian central venous catheter infusing propofol and intravenous fluids.
Heart sounds are regular.
The skin is pink.
Capillary refill is 6 seconds.
Radial pulses are equal bilaterally.
Lung sounds are clear and equal bilaterally.
The client has an indwelling urinary catheter in place.
No urine is noted.
The client has no visitors at this time.
The social worker is attempting to contact family members.
The client opens her eyes to verbal stimuli and follows verbal commands.
Based on these observations, what is the most appropriate nursing action?
Increase the rate of IV fluids.
Administer pain medication.
Monitor the client’s urine output.
Consult with the healthcare provider.
The Correct Answer is A
Choice A rationale
Increasing the rate of IV fluids is the most appropriate nursing action based on the client's clinical presentation. The client has signs of hypovolemia, including tachycardia, low blood pressure with a narrow pulse pressure, and delayed capillary refill. An IV fluid bolus is often prescribed to improve intravascular volume and perfusion. Monitoring the client's response to increased IV fluids is essential to ensure effective treatment.
Choice B rationale
Administering pain medication is important for managing the client's comfort, but it is not the priority action in this situation. The client's vital signs indicate hypovolemia, which needs to be addressed promptly. Pain management can be considered after stabilizing the client's hemodynamic status.
Choice C rationale
Monitoring the client's urine output is important for assessing renal perfusion and fluid balance. However, with the current clinical presentation indicating hypovolemia, the priority action is to increase the rate of IV fluids to improve intravascular volume and perfusion.
Choice D rationale
Consulting with the healthcare provider is important for collaborative care and decision-making. However, the priority action in this situation is to address the client's signs of hypovolemia by increasing the rate of IV fluids. Immediate intervention is needed to stabilize the client's hemodynamic status before further consultations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
Choice A rationale: Oxygen saturation of 56% is critically low and indicates severe hypoxemia, which requires immediate intervention to improve oxygenation and prevent life-threatening complications.
Choice D rationale: Tracheal deviation to the right suggests a possible tension pneumothorax, which is a medical emergency. It requires immediate attention to relieve the pressure on the affected lung and restore normal breathing.
Choice B rationale: Crackles heard in the right lung indicate fluid or atelectasis but are not immediately life-threatening compared to the other findings.
Choice C rationale: A pH of 7.21 indicates acidemia and respiratory acidosis but is a secondary concern compared to the immediate need to address the client's hypoxemia and potential tension pneumothorax.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale: Blood pressure of 90/79 mm Hg with a pulse pressure less than 40 mm Hg is concerning because it indicates hypotension and a narrowed pulse pressure, which can be signs of significant internal bleeding or shock. This requires immediate medical attention to stabilize the client's condition.
Choice B rationale: Oxygen saturation of 100% on 40% FiO₂ is not a critical finding that requires immediate reporting. The client is receiving sufficient oxygen, and the saturation level indicates adequate oxygenation.
Choice C rationale: Heart rate of 128 beats/minute, sinus tachycardia is an important finding because tachycardia can indicate a response to pain, anxiety, hypovolemia, or shock. It needs to be reported to assess and address the underlying cause.
Choice D rationale: CT scan findings of liver and spleen lacerations with blood in the peritoneum are critical because they indicate significant internal injuries and active bleeding. This requires immediate surgical intervention and close monitoring.
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