The nurse is assessing the client following the transfusion of 2 units of packed RBCs.

Exhibits

Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding click on the finding again

 

Laboratory Results

1800

• WBC count 6700/mm3 15.000 to 10.000/mm
• Hemoglobin 12 g/dl (14 to 18 g/dL)
• Hematocrit 36% (40% to 52%)

Vital Signs

1800

• Blood pressure 112/74 mm Hg
• Heart rate 95/min
• Respiratory rate 18/
• Temperature 37.5°C (95°F)
• Oxygen saturation 100% via 2 L/min nasal cannula

 

Rationale for correct choices

• obtain IV access: The client’s blood pressure has dropped significantly from 90/50 mm Hg to 76/45 mm Hg, and heart rate is elevated, indicating hypovolemic shock likely due to gastrointestinal bleeding. Establishing IV access is critical to provide rapid fluid resuscitation and allow administration of medications or blood products as needed.

• prepare to administer IV fluids: With hypotension and tachycardia, the client requires fluid resuscitation to restore circulating volume and improve perfusion prior to undergoing an invasive procedure like endoscopy. IV fluids will help stabilize hemodynamics and reduce the risk of complications during the procedure.

Rationale for incorrect choices

• recheck the client’s oxygen saturation: The client’s oxygen saturation is stable at 98% on room air, indicating adequate oxygenation. While monitoring is important, it does not address the more urgent issue of hypovolemia.

• call the surgical suite to notify that the client is arriving STAT: Notifying the suite is necessary for scheduling, but immediate intervention to stabilize the client’s hemodynamic status takes precedence over notification. Transport should not occur until the client is stabilized.

• place the client in a supine position with feet elevated: While this may provide temporary support for hypotension, it does not treat the underlying hypovolemia. IV access and fluid resuscitation are more effective and urgent interventions.

• check an ECG: Although ECG monitoring may be helpful in hypotensive clients, it is not the immediate priority over fluid resuscitation and IV access.

• check an arterial blood gas: ABG analysis is not immediately necessary because the client’s oxygenation is adequate and the priority is stabilizing circulation.

• transport the client for endoscopy: Transporting the client before hemodynamic stabilization would be unsafe given hypotension and tachycardia. Resuscitation must occur prior to the procedure.

Rationale:

A. Administer pancreatic enzymes with meals: Pancreatic enzymes are used to aid digestion in clients with pancreatic insufficiency, not for epiglottitis. This intervention is unrelated to the acute respiratory management required for this condition.

B. Carefully suction the child's oropharynx to remove secretions: Suctioning the oropharynx in a child with epiglottitis can trigger laryngospasm and complete airway obstruction. Suctioning should be avoided unless absolutely necessary and performed only by experienced personnel with emergency airway equipment ready.

C. Continuously monitor the child's respiratory status: Epiglottitis can rapidly progress to airway obstruction. Continuous assessment of respiratory rate, effort, oxygen saturation, and signs of distress is critical to detect deterioration early and initiate emergency interventions, making this a priority nursing action.

D. Instill normal saline drops to nares before meals: Nasal saline drops are used to relieve mild nasal congestion and facilitate feeding in children but do not address the life-threatening airway risk in epiglottitis. This is a supportive measure, not a priority intervention.