Temperature: 96.9 F (36.1 C) measured via internal probe via urinary catheter.
Heart rate: 128 beats/minute, sinus tachycardia (ST). Respirations: 14 breaths/minute.
Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg. Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2). IV fluid bolus given as prescribed.
The client’s surgical dressing is clean and dry.
Ecchymosis is noted on the abdomen around the dressing.
The client has a peripheral intravenous (PIV) line in the right forearm and one in the left hand.
The client also has a right subclavian central venous catheter infusing propofol and intravenous fluids.
Heart sounds are regular.
The skin is pink.
Capillary refill is 6 seconds.
Radial pulses are equal bilaterally.
Lung sounds are clear and equal bilaterally.
The client has an indwelling urinary catheter in place.
No urine is noted.
The client has no visitors at this time.
The social worker is attempting to contact family members.
The client opens her eyes to verbal stimuli and follows verbal commands.
Based on these observations, what is the most appropriate nursing action?
Increase the rate of IV fluids.
Administer pain medication.
Monitor the client’s urine output.
Consult with the healthcare provider.
The Correct Answer is A
Choice A rationale
Increasing the rate of IV fluids is the most appropriate nursing action based on the client's clinical presentation. The client has signs of hypovolemia, including tachycardia, low blood pressure with a narrow pulse pressure, and delayed capillary refill. An IV fluid bolus is often prescribed to improve intravascular volume and perfusion. Monitoring the client's response to increased IV fluids is essential to ensure effective treatment.
Choice B rationale
Administering pain medication is important for managing the client's comfort, but it is not the priority action in this situation. The client's vital signs indicate hypovolemia, which needs to be addressed promptly. Pain management can be considered after stabilizing the client's hemodynamic status.
Choice C rationale
Monitoring the client's urine output is important for assessing renal perfusion and fluid balance. However, with the current clinical presentation indicating hypovolemia, the priority action is to increase the rate of IV fluids to improve intravascular volume and perfusion.
Choice D rationale
Consulting with the healthcare provider is important for collaborative care and decision-making. However, the priority action in this situation is to address the client's signs of hypovolemia by increasing the rate of IV fluids. Immediate intervention is needed to stabilize the client's hemodynamic status before further consultations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1000"]
Explanation
Step 1 is 500 mL ÷ 30 min.
Step 2 is 16.67 mL/min × 60 min/hour. Answer: 1000 mL/hour.
Correct Answer is B
Explanation
Choice A rationale
Advancing from clear liquids as tolerated is important for the patient’s nutritional intake and postoperative recovery. However, it is not the most urgent task upon admission from the PACU. The nurse must first address immediate needs such as infection prevention and monitoring vital signs before considering dietary advancements. This step can be implemented once the patient’s initial postoperative stability is confirmed.
Choice B rationale
Administering cefazolin 1 gram IV every 6 hours is critical for preventing postoperative infections, especially in patients with surgical wounds. Prophylactic antibiotics are essential in reducing the risk of surgical site infections, which can lead to severe complications. Timely administration of antibiotics helps maintain therapeutic levels in the bloodstream, providing effective coverage against potential pathogens and promoting a positive postoperative outcome.
Choice C rationale
Straight catheterization if unable to void is important for managing urinary retention and preventing bladder distention. However, this intervention should be based on the patient’s condition and the amount of time since the last voiding. It is not the most urgent action upon admission from the PACU unless the patient is exhibiting signs of significant discomfort or bladder distention. Monitoring the patient’s urinary output is important but should follow the administration of prophylactic antibiotics.
Choice D rationale
Completing a blood cell count (CBC) in the morning is important for assessing the patient’s overall health and detecting any potential complications such as anemia or infection. However, it is not the most urgent action upon admission from the PACU. The nurse should prioritize tasks that address immediate postoperative needs, such as administering antibiotics and monitoring vital signs, before scheduling routine blood tests.
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