A nurse is assessing a client who has an abdominal incision. Which of the following findings should the nurse report to the provider?

Rationale:

A. Sit at or below the client's eye level during feedings: Positioning the nurse at or slightly below the client’s eye level promotes effective communication and allows close observation of swallowing. It helps the nurse monitor for signs of aspiration, coughing, or choking, which is critical in clients with dysphagia to ensure safety during meals.

B. Instruct the client to lift her chin when swallowing: Clients with dysphagia should be taught to tuck the chin slightly toward the chest, not lift it, to protect the airway and facilitate safer swallowing. Lifting the chin increases the risk of aspiration and airway compromise.

C. Talk with the client during her feeding: Talking while swallowing increases the risk of aspiration because it distracts the client and can disrupt coordinated swallowing. Silence and focused attention are recommended during feeding to ensure safe intake of food and liquids.

D. Discourage the client from coughing during feedings: Coughing is a protective reflex that clears the airway if food or liquid enters the trachea. Discouraging it could increase the risk of aspiration and choking, making it unsafe to suppress this natural defense mechanism.

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.