Exhibits

Click to mark whether the actions are indicated, contraindicated, or nonessential for this client. Each row must have one option selected.

A. Place a cooling blanket on the client. A temperature of 100°F (37.8°C) is only mildly elevated and does not require active cooling. The priority concern is hemodynamic instability due to hypovolemia, not fever management. Cooling blankets are typically used for high fevers (≥ 102°F or 38.9°C).
B. Administer an antipyretic agent. While fever may indicate postoperative infection or inflammatory response, the client’s most critical issue is hypotension and low urine output, suggesting hypovolemia or early shock. Treating the underlying cause (fluid loss) is more urgent than giving an antipyretic.
C. Give a 500 mL IV fluid bolus challenge. The client has tachycardia (132 bpm), hypotension (88/65 mm Hg), and oliguria (10 mL/hour), all of which suggest hypovolemic shock, a common postoperative complication. A fluid bolus (typically 500–1000 mL of isotonic crystalloid such as normal saline or lactated Ringer’s) is the first-line treatment to restore intravascular volume, improve blood pressure, and increase urine output.
D. Titrate IV vasopressor for systolic less than 80. Vasopressors (e.g., norepinephrine) are not the first-line treatment for hypovolemic shock. Fluids should be administered first to correct volume loss before considering vasopressors. If hypotension persists despite adequate fluid resuscitation, vasopressors may be initiated.

A. Apply high-flow oxygen by face mask. The client is in respiratory distress with absent breath sounds over the left lung field, which is highly suggestive of a pneumothorax or hemothorax. High-flow oxygen helps improve oxygenation while preparing for definitive intervention. In cases of tension pneumothorax, oxygen can help reduce hypoxia until a chest tube or needle decompression is performed.
B. Obtain a chest tube insertion kit. Absent breath sounds on one side following chest trauma strongly suggest a pneumothorax or hemothorax, requiring immediate chest tube placement to re-expand the lung and restore normal ventilation. The nurse should ensure that the equipment for thoracostomy (chest tube insertion) is readily available for the healthcare provider.
C. Withhold narcotic pain medication. Pain control is important in trauma patients, as uncontrolled pain can lead to shallow breathing, atelectasis, and respiratory complications. Narcotics should be used cautiously in clients with respiratory distress, but they are not contraindicated if given at appropriate doses with close monitoring.
D. Elevate the head of the bed 45 degrees. Clients with respiratory distress should be positioned with the head of the bed elevated to improve lung expansion. However, in a suspected pneumothorax, the priority is oxygenation and chest tube insertion. If there is hemodynamic instability, the client may require a flat or semi-Fowler’s position instead.
E. Place client in Trendelenburg position. The Trendelenburg position (head down, feet up) is not appropriate in chest trauma patients. This position can increase intra-abdominal pressure, worsen breathing difficulty, and impair lung expansion. It is typically avoided in clients with respiratory distress or suspected pneumothorax.