A nurse is caring for a client in the emergency department (ED)

 

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Rationale for correct choices:

• Obtain IV access: The client has hypotension (BP 90/50 mm Hg), tachycardia (HR 118/min), and significant anemia (Hgb 9.1 g/dL, Hct 27%), all of which suggest possible active gastrointestinal bleeding. Establishing IV access is a priority to allow rapid fluid resuscitation or blood product administration as needed.
• Prepare for a blood transfusion: Given the positive hemoccult stool, anemia, and vital sign changes, the client may require a blood transfusion to restore hemodynamic stability and oxygen-carrying capacity. Preparing for transfusion ensures timely intervention in case of worsening blood loss.

Rationale for incorrect choices:

• Call the surgical suite to notify that the client is arriving STAT: While the client is scheduled for endoscopy, immediate stabilization takes priority over notifying the surgical suite. The client’s hemodynamic status must be addressed first to prevent deterioration.
• Recheck the client's oxygen saturation: The client’s oxygen saturation is 98% on room air, which is within normal limits. Rechecking is not immediately necessary and does not address the urgent need for stabilization.
• Place the client in a supine position with feet elevated: Although elevating the feet can help improve perfusion temporarily, it does not treat the underlying anemia or hypotension and is less urgent than establishing IV access and preparing for transfusion.
• Offer oral fluids: Oral intake is contraindicated in a client at risk for endoscopy and possible GI bleeding. Fluids could increase the risk of aspiration and do not address hemodynamic instability.
• Administer PRN antacids: Antacids may provide minor symptom relief but do not treat active blood loss or stabilize the client before endoscopy.
• Document vital signs: Documentation is important but secondary to immediate interventions that address the client’s hypotension and potential hemorrhage.

Rationale for Correct Choice:

• Endometritis: The client's temperature of 38.2°C (100.8°F), foul-smelling lochia, and tender uterus are classic signs of this infection. The high WBC count of 33,000/mm3 further confirms the presence of a significant infection. The client's history of prolonged rupture of membranes and a cesarean section also increases the risk.
• Uterus and lochia assessment: The specific findings of a tender uterus and foul-smelling lochia are the most direct evidence of a uterine infection. The uterus is the primary site of infection in endometritis, and the lochia (postpartum vaginal discharge) reflects the state of the uterine lining.

Rationale for Incorrect Choices:

• Mastitis: While the client reports firm, warm, and tender breasts, mastitis is usually unilateral and accompanied by localized redness and systemic symptoms like fever. In this case, the fever and uterine findings point more toward uterine infection.
• Pneumonia: Lung sounds are clear but diminished; there are no crackles, wheezing, or other respiratory symptoms such as cough or shortness of breath that would indicate pneumonia. The primary infection source appears obstetric, not pulmonary.
• Lung sounds (breath assessment): Diminished breath sounds alone are insufficient to diagnose pneumonia. The client’s main indicators of infection involve the uterus and lochia rather than respiratory compromise.
• Breast and nipple changes: Though mild breast tenderness is noted, these findings do not account for the systemic symptoms and uterine signs, making mastitis less likely as the primary diagnosis.