Patient Data

 

Exhibits

The nurse is reviewing the client's initial assessment findings.
Which assessment findings require follow-up? Select all that apply.

A. Soft abdomen, absent bowel sounds, no bleeding on dressing: This provides relevant post-operative assessment information, but it reflects the current status rather than additional history affecting immediate care priorities.

B. Peripheral pulses present with full range of motion of both legs: This is important for neurovascular assessment, but it is already covered in routine PACU reporting and does not represent additional critical information.

C. Declining to take ice chips despite reporting of dry mouth: While this may affect hydration and comfort, it does not significantly alter immediate post-operative management and can be addressed by the receiving nurse.

D. History of vomiting at home for 3 days prior to surgery: This is significant additional information because prolonged preoperative vomiting can lead to fluid and electrolyte imbalances, increasing the risk for complications post-operatively. The receiving nurse needs to be aware to guide monitoring and interventions.

Rationale for correct choices:

• Anemia: The client’s hemoglobin (9.3 g/dL) and hematocrit (30%) are both below normal, which indicates a reduced oxygen-carrying capacity of the blood, consistent with anemia.

• Blood loss: The abdominal hematoma, distension, and need for fluid bolus suggest internal bleeding after trauma, leading to a significant drop in hemoglobin and hematocrit.

• Hemodilution from intravenous fluids: The client received large volumes of IV fluids (bolus and maintenance infusion), which dilute circulating red blood cells, worsening the anemia picture.

Rationale for incorrect choices:

• Acidosis: No arterial blood gas (ABG) results are available yet, so there is no evidence to confirm a metabolic or respiratory acidosis at this stage.

• Hypovolemia: The client initially showed low blood pressure and tachycardia, but stabilization with fluids improved her vitals; the lab values specifically indicate anemia, not pure hypovolemia.

• Disseminated intravascular coagulation: PT and PTT are within normal limits, with no signs of uncontrolled clotting or bleeding, so DIC is not supported.

• Rh factor sensitization: The client is B+, but there is no mention of pregnancy or transfusion reactions that would trigger Rh-related hemolysis.

• Pregnancy: No history, findings, or labs indicate pregnancy, so this option is unrelated to the client’s current trauma and blood results.

• Hypoxia: Oxygen saturation remains 98–100% on mechanical ventilation, showing adequate oxygenation despite anemia.

• Blood administration: While the client may need transfusion, labs reflect anemia caused by blood loss and hemodilution, not from receiving blood products.

• Immune response: There are no clinical or laboratory findings of immune-mediated destruction of red cells or inflammation causing the anemia.

• Clotting cascade: Normal PT and PTT show the coagulation pathway is intact, ruling out clotting disorders as the cause of low hemoglobin and hematocrit.

• Hypoventilation: The client is mechanically ventilated with normal oxygenation, and there is no evidence of hypoventilation contributing to her anemia.