Exhibits

The nurse evaluates the client and the flow sheet.

Click to highlight the findings that indicate the client is progressing as expected.

The client presents to the office for reevaluation of rheumatoid arthritis after methotrexate 25 mg PO weekly was started at the last visit. The client reports she has been balancing periods of activity with rest. She recently attended a large family wedding and became fatigued quickly. She has continued to garden, and read, but crocheting is too painful. She is tolerating weekly medication without side effects. She describes pain as 1 to 2 on a 0 to 10 pain scale in bilateral hands. She has noticed "heartburn" about an hour after using ibuprofen for pain relief. The client is pleased with the improvements.

Rationale for Correct Choices:

• Anemia: The lab values indicate that the client’s hemoglobin and hematocrit are lower than normal, suggesting anemia. Anemia in this case is likely due to blood loss from the trauma, as the client has internal hemorrhaging, with blood noted in the peritoneum.
• Blood loss: The client’s abdominal trauma, with liver and spleen lacerations and blood in the peritoneum, is a clear indicator of significant internal bleeding. This blood loss is directly responsible for the anemia seen in the lab results.
• Hemodilution from intravenous fluids: The client is receiving IV fluids at a rate of 100 mL/hr, which can dilute the blood and artificially lower hematocrit and hemoglobin levels. This is a common effect when fluids are given in large amounts, as the fluid increases plasma volume without immediately increasing red blood cells.

Rationale for Incorrect Choices:

• Acidosis: Acidosis typically presents with changes in blood pH and respiratory or renal compensation, which is not indicated by the client's lab results or current status. There are no signs of metabolic or respiratory acidosis in the current clinical picture.
• Rh factor sensitization: Rh factor sensitization usually occurs during pregnancy when Rh-negative mothers develop antibodies against Rh-positive fetal blood cells. This is unrelated to the client’s trauma and lab findings, which focus on anemia.
• Hypovolemia: Hypovolemia is more directly related to the blood loss and the hemodilution effect from intravenous fluid administration, making it a contributing but less specific factor in the anemia diagnosis.
• Disseminated intravascular coagulation (DIC): DIC is characterized by widespread clotting followed by bleeding. There is no evidence of abnormal clotting or bleeding issues in the lab results or clinical presentation, such as abnormal coagulation studies.
• Pregnancy: Pregnancy is not applicable in this case as the client's history does not mention any signs or symptoms of pregnancy. Anemia in this patient is related to trauma-induced blood loss and subsequent hemodilution, not pregnancy-related causes.
• Clotting cascade: While it is relevant to conditions like DIC or bleeding disorders, it does not directly explain the client's low hemoglobin or hematocrit. The lab results are more consistent with blood loss and fluid resuscitation.
• Blood administration: There is no mention of the client receiving blood products. While blood transfusion might be needed given the blood loss, there is no current indication from the lab results that blood administration has occurred or is required at this point.
• Immune response: An immune response is typically seen in infections or allergic reactions. The client’s current clinical condition and lab results do not suggest an infection or immune response but rather trauma-related blood loss and fluid effects.
• Hypoventilation: Hypoventilation typically leads to respiratory acidosis or elevated CO2 levels, but the client is intubated and on mechanical ventilation, with no indication of respiratory distress or acidosis.
• Hypoxia: Although trauma patients may experience hypoxia, the client’s oxygen saturation is 100%, and there is no indication of respiratory distress or hypoxia in the lab results. The anemia is more related to blood loss rather than a lack of oxygen in the tissues.

A. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet: Documenting a previous reading does not reflect the client’s current condition and can be misleading in decision-making. Vital signs should be based on real-time assessment.

B. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed: The popliteal site is appropriate for measuring blood pressure when the arms are inaccessible. Flexing the knee while the client is supine allows better access to the artery and enables accurate assessment of blood pressure in this situation.

C. Document why the blood pressure cannot be accurately measured at the present time: While documentation is necessary if no alternative is available, the nurse must first exhaust appropriate options for obtaining a blood pressure before choosing to omit it.

D. Estimate the blood pressure by assessing the pulse volume of the client's radial pulses: Pulse volume gives a very rough estimate of perfusion but does not provide an accurate or objective blood pressure measurement. This method lacks precision.