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 ["A","B","E"]
Explanation
Choice A rationale: Involving the mother in the decision-making process can help reduce caregiver stress by sharing the responsibility and ensuring that the client's preferences and needs are considered. This collaborative approach can lead to better outcomes and improved communication.
Choice B rationale: It is important to acknowledge that caregiving can be challenging and can affect emotions. Recognizing that it is okay to have complex feelings, including not always loving or liking the person being cared for, helps normalize these emotions and reduces guilt and stress.
Choice C rationale: Moving a loved one into a care facility can be a difficult decision, but it does not necessarily mean a lack of love. However, this statement is not appropriate as it may reinforce negative emotions and guilt.
Choice D rationale: Avoiding the discussion of negative situations that may occur in the future is not helpful. It is important to plan for potential challenges to be prepared and reduce stress.
Choice E rationale: Saying "no" to things involving the care of a loved one is not selfish. It is important to set boundaries and prioritize self-care to prevent caregiver burnout. However, this statement suggests the opposite and is not appropriate.
Choice F rationale: Taking time for oneself and maintaining other important relationships is essential for a caregiver's well-being. Self-care and social support can help reduce stress and improve the ability to provide care effectively.
Correct Answer is C
Explanation
Choice A rationale
While asking the client's family to return may provide additional support, it is not a viable long-term solution as family members may have other responsibilities and commitments. It also places undue pressure on the family.
Choice B rationale
Hiring a private nurse could be a solution, but it may not be financially feasible for all clients. It also does not address the need for a comprehensive plan for both the client and her husband.
Choice C rationale
Social services can assist in arranging respite care for the client's husband, ensuring he receives the necessary care while the client recovers. Respite care is a practical solution for temporary relief for caregivers.
Choice D rationale
A case management evaluation can help assess the client's home environment and identify any potential needs or risks. However, it does not directly address the immediate concern of providing care for the husband.
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