A nurse is caring for a 24-year-old female client who fell while horseback riding in the accident emergency unit.

Exhibits

A nurse is preparing the client for surgery. Based on the provided data, which of the following are the most critical to address before proceeding with the exploratory laparotomy? Select all that apply.

Choice A rationale: Hemoglobin of 9.3 g/dL indicates that the client has anemia, likely due to blood loss from the injury. This low hemoglobin level suggests significant bleeding, which needs to be addressed to ensure adequate oxygen delivery to tissues during surgery.

Choice B rationale: Prothrombin time of 11.5 seconds is within the normal range and does not indicate a critical issue that needs to be addressed before surgery. It suggests that the client's blood clotting mechanism is functioning properly.

Choice C rationale: Blood pressure of 90/48 mm Hg indicates hypotension, which is a sign of shock or significant blood loss. It is critical to stabilize the client's blood pressure to ensure adequate perfusion to vital organs during surgery.

Choice D rationale: Heart rate of 110 beats/minute is elevated, which may be a response to pain, anxiety, or hypovolemia. While it is important to monitor, it is not as critical as addressing the hypotension and anemia before surgery.

Choice E rationale: Abdominal distention indicates potential internal bleeding or injury to abdominal organs. This needs to be addressed urgently, as it can lead to further complications and affect the outcome of the surgery.

Choice A rationale

Informing the client that the nurse is busy and will talk to him later is a professional and appropriate response. This approach acknowledges the client's need for attention while setting a clear boundary that respects the nurse's current responsibilities. It also provides a time frame for when the client can expect to receive attention, which can help reduce anxiety or agitation. This method promotes orderly and efficient care without compromising the needs of the newly admitted client.

Choice B rationale

Putting the client's behavior on extinction by not acknowledging it might seem effective, but it can lead to feelings of being ignored or dismissed. This approach is not therapeutic in a psychiatric setting, where clients often require validation and structured interactions. Ignoring a client's request can escalate the behavior or contribute to a sense of isolation. Therapeutic communication involves active listening and responding appropriately to all clients.

Choice C rationale

Introducing the client to the newly admitted client and asking him to join the conversation can be disruptive and inappropriate. This action may not address the urgency of the client's concern and can intrude on the privacy and focus needed for the newly admitted client. It is important to maintain a structured and private environment for admissions to ensure that the new client feels supported and understood.

Choice D rationale

Encouraging the client to go to the nurse's station and talk with another nurse may not be practical, especially if the other nurses are also occupied. This response can seem dismissive and may not adequately address the client's immediate concern. It is more effective to provide a clear time frame or alternative solution for when the client will receive attention. Proper delegation requires ensuring that the alternative option is available and can provide the necessary support.