A client presents to the emergency department with nausea, vomiting, and diarrhea. While obtaining the history and physical assessment, the nurse discovers that the client's significant other is recovering from COVID 19. After obtaining a nasal swab to test the client for COVID 19, which action is most important for the nurse to take?

Rationale

A. In heart failure exacerbation, decreased cardiac output can lead to poor peripheral perfusion, potentially manifesting as weak or diminished pedal pulses. However, in the context of acute symptoms such as palpitations or chest discomfort, assessing the rhythm and rate of central pulses (like the apical pulse) may be more immediate and informative.

B. Capillary refill time assesses peripheral perfusion and can indicate circulatory status. Prolonged capillary refill (>2 seconds) may indicate poor perfusion, which could occur in heart failure exacerbation due to reduced cardiac output. It is a valuable assessment, but in this scenario, focusing on more central aspects such as the heart rhythm is typically more immediate.

C. Assessing the rhythm of the apical pulse is crucial in this scenario. The client's sensation of "flopping" in the chest suggests palpitations or irregular heartbeats, which could indicate arrhythmias such as atrial fibrillation or other dysrhythmias.

D. Skin elasticity primarily assesses hydration status and may provide information about overall skin integrity but is less directly related to the acute symptoms described by the client. While important in general assessments, it does not directly address the urgent need to assess for arrhythmias or irregular heartbeats.

Rationale

A. Acute pain following laser trabeculoplasty could indicate increased intraocular pressure, inflammation, or other complications. Reporting the pain to the surgeon allows for prompt evaluation and intervention, which may include further assessment of intraocular pressure, examination of the surgical site, and consideration of additional treatment modalities such as pain management or anti- inflammatory medications.

B. Postoperative antibiotics are typically prescribed to prevent infection after surgery. However, acute pain alone may not indicate an infection, and starting antibiotics without assessing the cause of pain could delay appropriate management. Antibiotics are not indicated as the first-line response to acute pain in this context.

C. Eye shields are commonly used after eye surgery to protect the eye from light and potential trauma. While important for protecting the eye, applying eye shields addresses a different aspect of postoperative care (protecting the eye from external factors), rather than addressing the acute pain reported by the client.

D. Nausea and vomiting can sometimes occur postoperatively due to anesthesia or medications. However, administering an antiemetic is not the appropriate action in response to acute eye pain following laser trabeculoplasty. It does not address the underlying cause of the pain and is not part of the standard immediate management for this situation.