A nurse is reinforcing teaching with a client who is taking diltiazem sustained-release tablets for hypertension. Which of the following instructions should the nurse include?

Heart rate
• Hypovolemic Shock
o The elevated heart rate of 104/min is consistent with hypovolemic shock, where the body compensates for reduced blood volume by increasing heart rate to maintain cardiac output and perfusion.
• Pulmonary Embolism
o An increased heart rate can also occur with pulmonary embolism as the body responds to decreased oxygenation and impaired cardiac function.
Respiratory effort
• Hypovolemic Shock
o Increased respiratory rate of 24/min may be a compensatory mechanism in hypovolemic shock to enhance oxygen delivery to tissues despite reduced blood volume.
• Pulmonary Embolism
o Elevated respiratory rate can also be seen in pulmonary embolism due to impaired gas exchange and increased respiratory effort to compensate for decreased oxygen levels.
Pain
• Pulmonary Embolism
o Pain, particularly pleuritic chest pain, is a common symptom of pulmonary embolism and could be indicative of embolic obstruction in the pulmonary circulation.
Blood pressure
• Hypovolemic Shock
o The drop in blood pressure to 88/54 mm Hg is consistent with hypovolemic shock, where reduced blood volume leads to decreased perfusion and hypotension.
Mentation
• Hypovolemic Shock
o Altered mentation, such as restlessness or agitation, can be a sign of hypovolemic shock as decreased perfusion affects brain function and consciousness.
• Pulmonary Embolism
o Changes in mentation can also occur in pulmonary embolism due to hypoxemia or decreased perfusion to the brain.

A. Obtain vital signs every 5 min.

Rationale: The client's vital signs indicate hypotension (blood pressure 88/54 mm Hg) and tachycardia (heart rate 104/min). Frequent monitoring of vital signs is essential to assess changes in the client's condition and guide further interventions.

E. Initiate a second peripheral IV.

Rationale: Given the client's low urine output (110 mL over 6 hours) and signs of possible hypovolemia or fluid imbalance, establishing an additional IV line can facilitate the administration of fluids and medications more effectively.

F. Apply oxygen.

Rationale: The client's oxygen saturation is slightly decreased at 96% on room air. Applying supplemental oxygen can help improve oxygenation and alleviate symptoms related to decreased oxygen levels.

Not Recommended Actions:

B. Place the client in high-Fowler's position: This position might not be appropriate for a client with chest pain and potential hypovolemia, as it could exacerbate hypotension.

C. Perform gastric lavage: The output from the nasogastric tube (800 mL sanguineous) does not indicate a need for gastric lavage unless there is a specific reason to suspect gastrointestinal bleeding that requires immediate intervention.

D. Prepare to administer anticoagulants: There is no indication of thromboembolism or need for anticoagulants based on the provided information. The focus should be on addressing hypotension and fluid imbalance.