The medical-surgical nurse is caring for a 55-year-old female patient after surgery. The patient's respiratory rate has increased from 12 to 22 breaths/min, and the pulse rate has increased from 86 to 110 beats/min since the patient was last assessed 4 hours ago. What action by the nurse is best?
Assess the patient's tissue perfusion further.
Ask if the patient needs pain medication.
Document the findings in the patient's chart.
Increase the rate of the patient's IV infusion.
The Correct Answer is A
The increased respiratory rate and pulse rate can be indicators of physiological changes or potential complications in the patient's condition. These changes may suggest alterations in tissue perfusion or other underlying issues that require further assessment.
Assessing the patient's tissue perfusion includes evaluating additional vital signs, such as blood pressure, oxygen saturation, and capillary refill time. Assessing skin color, temperature, and moisture, as well as peripheral pulses, can also provide important information regarding tissue perfusion.
B. Pain medication (option B) is incorrect because the increased respiratory and pulse rates could also indicate other factors that require assessment before administering pain medication.
C. Documenting the findings in the patient's chart (option C) is incorrect because it should not be the primary action at this point. Assessing the patient's condition and determining appropriate interventions take priority.
D. Increasing the rate of the patient's IV infusion (option D) is incorrect because may not be the most appropriate action without further assessment. The patient's increased respiratory and pulse rates may not necessarily be related to hydration status, and it is important to assess the patient comprehensively before making changes to the IV infusion rate.
Therefore, the best action by the nurse in this situation is to further assess the patient's tissue perfusion to gather more information and determine the appropriate course of action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Heart rate: 72 beats per minute Stroke volume: 90 mL/contraction
Cardiac output = Heart rate × Stroke volume
Cardiac output = 72 beats/minute × 90 mL/contraction
To simplify the calculation, you can convert the units:
72 beats/minute × 90 mL/contraction = (72 × 90) beats/minute × mL/contraction
Now, perform the multiplication:
72 × 90 = 6,480
Therefore, the cardiac output is 6,480 mL per minute.
The correct answer is:
C. 6,480 mL
Correct Answer is A
Explanation
Tachypnoea, which refers to an increased respiratory rate, is an early symptom of hypovolemic shock. It is the body's compensatory response to inadequate tissue perfusion and decreased oxygen delivery. The increased respiratory rate is an attempt to improve oxygenation and maintain vital organ function.
B. Heart blocks in (option B) are incorrect because Heart blocks refer to disruptions in the electrical conduction system of the heart and are not specific to hypovolemic shock.
C. Vomiting in (option C) is incorrect because: Vomiting may occur in various conditions, including shock, but it is not exclusive to hypovolemic shock and can be present in other forms of shock or illnesses.
D. Bradycardia in (option D) is incorrect because Bradycardia, or a slow heart rate, is not typically an early symptom of hypovolemic shock. Instead, tachycardia (rapid heart rate) is more commonly observed as a compensatory response to maintain cardiac output.
E. Hypotension in (option E) is incorrect because Hypotension, or low blood pressure, can occur in hypovolemic shock but is generally considered a later-stage symptom. In the early stages, compensatory mechanisms may help maintain blood pressure, so hypotension may not be present initially.
F. Bradypnea in (option F) is incorrect because: Bradypnea refers to a slow respiratory rate, which is not typically an early symptom of hypovolemic shock. Tachypnoea, as mentioned earlier, is the more common early respiratory symptom.
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