A nurse case manager is caring for a population of clients in the community. Which of the following demonstrates the role of a liaison?

Rationale for correct choices

• obtain IV access: The client’s blood pressure has dropped significantly from 90/50 mm Hg to 76/45 mm Hg, and heart rate is elevated, indicating hypovolemic shock likely due to gastrointestinal bleeding. Establishing IV access is critical to provide rapid fluid resuscitation and allow administration of medications or blood products as needed.

• prepare to administer IV fluids: With hypotension and tachycardia, the client requires fluid resuscitation to restore circulating volume and improve perfusion prior to undergoing an invasive procedure like endoscopy. IV fluids will help stabilize hemodynamics and reduce the risk of complications during the procedure.

Rationale for incorrect choices

• recheck the client’s oxygen saturation: The client’s oxygen saturation is stable at 98% on room air, indicating adequate oxygenation. While monitoring is important, it does not address the more urgent issue of hypovolemia.

• call the surgical suite to notify that the client is arriving STAT: Notifying the suite is necessary for scheduling, but immediate intervention to stabilize the client’s hemodynamic status takes precedence over notification. Transport should not occur until the client is stabilized.

• place the client in a supine position with feet elevated: While this may provide temporary support for hypotension, it does not treat the underlying hypovolemia. IV access and fluid resuscitation are more effective and urgent interventions.

• check an ECG: Although ECG monitoring may be helpful in hypotensive clients, it is not the immediate priority over fluid resuscitation and IV access.

• check an arterial blood gas: ABG analysis is not immediately necessary because the client’s oxygenation is adequate and the priority is stabilizing circulation.

• transport the client for endoscopy: Transporting the client before hemodynamic stabilization would be unsafe given hypotension and tachycardia. Resuscitation must occur prior to the procedure.

Rationale:

A. Peripheral edema is present: Peripheral edema indicates fluid overload rather than restored fluid balance. Excess interstitial fluid reflects that the body has retained more fluid than necessary, which is a sign that fluid status is not yet normalized.

B. Crackles upon auscultation of the lungs: Lung crackles suggest pulmonary congestion, which is a sign of fluid overload. This finding indicates that fluid replacement may have exceeded the client’s needs, so fluid balance has not been restored appropriately.

C. Maternal heart rate is 110/min: Tachycardia can indicate ongoing hypovolemia or stress on the cardiovascular system. A normalized fluid balance would typically correspond with a heart rate within the client’s baseline range, generally around 60–100/min, rather than persistent tachycardia.

D. Urine output for 1 hour is 35 mL: Adequate urine output (generally ≥30 mL/hr for adults) indicates effective renal perfusion and suggests that intravascular volume has been restored. This is a key clinical indicator of fluid balance normalization following hemorrhage and fluid replacement.