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 C
Explanation
Choice A rationale
Consulting with a nurse who shares the same religious beliefs may provide insight, but it may not fully address the client's unique care preferences and individual needs.
Choice B rationale
Researching the religion on social media platforms can offer information, but it is not a substitute for understanding the client's specific preferences and requirements.
Choice C rationale
Asking the client about individual care preferences is the best approach, ensuring that care is personalized and respectful of the client's religious beliefs, leading to better compliance and satisfaction.
Choice D rationale
Explaining that every client receives the same high level of care is important but does not address the client's specific religious concerns and preferences.
Correct Answer is D
Explanation
Choice A rationale
An older client one day postoperative with a colostomy for colon cancer may have complex needs that require the expertise of an RN rather than a PN.
Choice B rationale
An older adult scheduled for foot amputation due to diabetes complications may also have complex needs and potential complications that necessitate the supervision of an RN.
Choice C rationale
An adult with alcoholism, cirrhosis, and hepatic encephalopathy is likely to have complex medical issues and require close monitoring and interventions, best suited for an RN.
Choice D rationale
An adult one day postoperative for a laparoscopic cholecystectomy is generally stable and has less complex needs, making them an appropriate assignment for a PN.
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