A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock?

Choice A Reason: This is incorrect. The balloons should not be deflated without a physician's order, as this can cause rebleeding or aspiration.

Choice B Reason: This is incorrect. The head of the bed should be elevated to 30 to 45 degrees to reduce pressure on the balloons and prevent gastric reflux.

Choice C Reason: This is correct. The nurse should monitor the client closely for signs of complications, such as airway obstruction, aspiration, or balloon rupture. The nurse should also keep scissors at the bedside to cut the tube and release the balloons in case of an emergency.

Choice D Reason: This is incorrect. The tube should not be suctioned, as this can damage the mucosa and cause bleeding. The nurse should only aspirate gastric contents through the gastric lumen to decompress the stomach.

Choice A Reason: This is incorrect because the results are not within the expected reference range. The client's BUN, creatinine, and hematocrit are elevated, indicating dehydration or reduced renal perfusion.

Choice B Reason: This is correct because evaluating urine for amount and for specific gravity can help assess the client's hydration status and renal function. These actions can help assess the client's hydration status and renal function, which may be affected by nausea and vomiting. The client's BUN, creatinine, and hematocrit are elevated, indicating dehydration or reduced renal perfusion. The normal ranges for BUN are 7 to 20 mg/dL, for creatinine are

0.6 to 1.2 mg/dL, and for hematocrit are 38% to 50% for males. The nurse should monitor the urine output and specific gravity, which reflect the concentration and volume of urine. The normal range for urine output is 30 to 60 mL/hour, and for specific gravity is 1.005 to 1.030.

Choice C Reason: This is incorrect because collecting a urine specimen for culture and sensitivity is not indicated for this client. This action is used to diagnose urinary tract infections, which are not suggested by the client's symptoms or results.

Choice D Reason: This is incorrect because decreasing the IV fluid infusion rate and limiting oral fluid intake can worsen the client's dehydration and renal perfusion. The nurse should maintain adequate fluid intake and balance to prevent further complications.