The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (SELECT ALL THAT APPLY).

A) Increased cardiac output:
While cardiac output is an important factor in shock management, the primary goal of nursing care is not specifically to increase cardiac output. Shock typically involves inadequate tissue perfusion, which may be caused by a variety of factors including low cardiac output, vasodilation, or fluid imbalance. The focus of nursing care is to restore adequate perfusion to tissues, which may involve improving cardiac output as part of a larger therapeutic strategy.

B) Inadequate tissue perfusion:
The primary goal in the treatment of shock is to restore adequate tissue perfusion, as shock is defined by a failure of the circulatory system to supply sufficient oxygen and nutrients to the body's tissues and organs. Inadequate tissue perfusion can lead to organ dysfunction and, if not addressed, can result in organ failure and death. Nursing interventions are aimed at improving perfusion through fluid resuscitation, vasoactive medications, and other strategies to ensure that oxygen and nutrients are delivered to vital organs.

C) Fluid overload or deficit:
Managing fluid status is crucial in shock, as fluid imbalance (either overload or deficit) can exacerbate the condition. However, fluid overload or deficit is not the primary focus; rather, it is one aspect of managing inadequate tissue perfusion. For example, in hypovolemic shock, the nurse would manage fluid deficit, while in cardiogenic shock, the focus would be on optimizing fluid balance without causing overload.

D) Vasoconstriction of vasculature:
While vasoconstriction can be a compensatory mechanism in certain types of shock (e.g., hypovolemic shock), the primary goal is not to induce vasoconstriction per se. In some cases, vasodilation may occur (as in septic shock), and vasoconstriction could be harmful. The goal is to optimize the vascular tone and perfusion, which may involve vasodilation or vasoconstriction depending on the type of shock.

A) Encourage the client to ambulate and perform deep breathing exercises:
While ambulation and deep breathing exercises are important for post-operative recovery, they are not the priority intervention in this scenario. The client is presenting with abdominal distension and pain, which could indicate a potential complication such as bowel obstruction, ileus, or internal bleeding. These symptoms need to be thoroughly evaluated by the healthcare provider to rule out serious complications.

B) Notify the healthcare provider and prepare the client for further testing:
The combination of abdominal pain and distension in a client who is four days post-operative for an abdominal aortic aneurysm repair is concerning for potential complications such as bowel ischemia, internal bleeding, or post-operative ileus. It is essential to notify the healthcare provider immediately for further assessment and possible diagnostic tests, such as imaging or a physical exam to evaluate for signs of ischemia or obstruction

C) Document the client's symptoms and continue to monitor:
Although documenting and monitoring the client's symptoms is important in nursing care, it is not the most appropriate immediate response. Given the symptoms, including pain and abdominal distension, there is a potential for a serious complication, and simply continuing to monitor without notifying the healthcare provider could delay diagnosis and treatment.

D) Administer pain medication and explain this is normal:
While it is important to manage the client's pain, explaining that the symptoms are "normal" could lead to a delay in identifying a potentially serious issue. Abdominal distension and pain post-operatively in a patient who has undergone abdominal surgery should never be assumed to be a normal part of recovery without further investigation.