A nurse is teaching a newly licensed nurse about reducing the risk of needlestick injuries. Which of the following instructions should the nurse include?

Blood pressure 86/46 mm Hg

A blood pressure of 86/46 mm Hg indicates hypotension. Hypotension can be a sign of inadequate perfusion and may lead to organ dysfunction if not promptly addressed. Immediate action may include reassessment of the client's hemodynamic status, fluid resuscitation if indicated, and consideration of vasopressor medications under provider orders.

Oxygen saturation 94% on 2 L via nasal cannula

Although the oxygen saturation of 94% is within the acceptable range (typically ≥ 92% for most clients),

it should be monitored closely as per the prescribed titration to maintain ≥ 92%. If the oxygen saturation drops below the target range, the nurse may need to adjust the oxygen flow rate or consider alternative oxygen delivery methods to ensure adequate oxygenation.

Prescription for the transfusion of 2 units of packed RBCs

Transfusion of packed red blood cells (RBCs) is indicated, suggesting the client may have significant anemia or ongoing bleeding requiring correction of hemoglobin levels. Immediate action involves verifying the blood product compatibility, initiating transfusion per protocol (including pre-transfusion assessments), and monitoring the client closely for any signs of transfusion reaction or complications during the transfusion.

Pulse rate 100/min, respiratory rate 28/min

Elevated pulse rate (tachycardia) and respiratory rate (tachypnea) can indicate physiological stress, inadequate oxygenation, or compensation for decreased cardiac output due to hypotension. These vital signs should be closely monitored for any worsening trends or signs of instability that may require immediate intervention, such as further assessment for hypovolemia or respiratory distress.

A. Delayed gastric emptying (gastroparesis) typically manifests with symptoms related to the gastrointestinal system, such as nausea, vomiting, bloating, and early satiety. It does not cause changes in lung auscultation findings.
B. Pulmonary edema is characterized by the accumulation of fluid in the lungs, leading to symptoms such as shortness of breath, crackles (rales) on lung auscultation, and possibly decreased oxygen saturation. While pulmonary edema can cause abnormal lung sounds, it is less likely in a client recovering from a lacerated spleen unless there are additional complications or comorbidities.
C. Atelectasis refers to the collapse or closure of a part of the lung, resulting in reduced or absent air exchange. It can occur due to prolonged bedrest, shallow breathing, or conditions that restrict lung expansion. A client who has been on bedrest for several days is at increased risk for developing atelectasis, especially in the lower lobes where ventilation may be compromised. Decreased breath sounds in the lower lobes suggest atelectasis as a likely condition.
D. An upper respiratory infection typically affects the upper airways (nose, throat, sinuses), causing symptoms such as nasal congestion, sore throat, cough, and sometimes fever. Lung auscultation findings in an upper respiratory infection are more likely to include rhonchi or wheezes rather than decreased breath sounds in the lower lobes.