You are the nurse-manager in the burn unit.
Which client is best assigned to an RN who has floated from the oncology unit?

Choice A rationale

Chest pain after a percutaneous coronary intervention is a critical finding that suggests acute re-occlusion of the coronary artery, stent thrombosis, or vasospasm. A pain level of 8 on a 10-point scale is severe and indicates myocardial ischemia is likely occurring. This requires immediate intervention to prevent further myocardial infarction. The nurse must assess the patient, notify the physician, and likely prepare for emergency pharmacological or repeated surgical intervention to restore blood flow.

Choice B rationale

Pedal pulses rated as 2+ are considered normal and indicate adequate peripheral perfusion to the lower extremities. In the context of a post-PCI patient where the femoral artery may have been used for access, 2+ pulses suggest that there is no major vascular complication or hematoma obstructing blood flow to the limb. While pulses should be monitored regularly, this finding is stable and does not require an immediate emergency response from the nursing staff.

Choice C rationale

A blood pressure of 104/56 mm Hg is slightly low but may be expected following the administration of nitrates or beta-blockers during a PCI procedure. While it requires monitoring, it is not as immediately life-threatening as severe chest pain. The mean arterial pressure is approximately 72 mm Hg, which is above the 65 mm Hg threshold needed to maintain vital organ perfusion. It does not represent the same level of acute cardiac distress as ischemia.

Choice D rationale

A heart rate of 100 beats/min is at the upper limit of the normal range, which is 60 to 100 beats/min. Tachycardia can be caused by pain, anxiety, or mild dehydration post-procedure. While the nurse should investigate the cause, a heart rate of 100 is not inherently an emergency unless accompanied by rhythm changes or symptoms of heart failure. It is secondary in priority to the patient reporting severe, acute chest pain.

Choice A rationale

Compensated hypovolemic shock typically presents with tachycardia as the heart attempts to maintain cardiac output in the face of low volume. Furthermore, the skin is usually cool, pale, and clammy due to peripheral vasoconstriction. In this scenario, the patient is bradycardic with a heart rate of 45 beats/min and has warm, flushed skin, which directly contradicts the clinical presentation of hypovolemia where systemic vascular resistance would be elevated.

Choice B rationale

An allergic reaction or anaphylactic shock involves a massive release of histamine, leading to vasodilation and hypotension. While it can cause flushed skin, it is almost universally accompanied by tachycardia as the body compensates for the drop in blood pressure. The presence of significant bradycardia following a high cervical spine injury strongly points toward a neurological cause rather than an immunological trigger or a hypersensitivity response to an external allergen.

Choice C rationale

A cervical spine injury at C-5 can cause neurogenic shock by interrupting the sympathetic nervous system pathways. This results in loss of vasomotor tone, causing massive vasodilation and warm, flushed skin. Crucially, the loss of sympathetic input to the heart prevents tachycardia, leading to bradycardia despite hypotension. Normal heart rates range from 60 to 100 beats/min, and blood pressure should be around 120÷80 mm Hg, making these findings classic for neurogenic shock.

Choice D rationale

While warm skin can sometimes indicate a fever, the combination of profound hypotension and bradycardia in the context of a diving accident and potential spinal cord injury is pathognomonic for a circulatory collapse of neural origin. An elevated temperature alone would typically cause a compensatory increase in heart rate to meet the metabolic demands of the body. The primary concern here is the hemodynamic instability resulting from the spinal trauma.