The nurse gets the hand-off report on four clients. Which client ...

[dalyningkenk]

The nurse gets the hand-off report on four clients. Which client should the nurse assess first?
 
  a. Client with a blood pressure change of 128/74 to 110/88 mm Hg
  b. Client with oxygen saturation unchanged at 94
  c. Client with a pulse change of 100 to 88 beats/min
  d. Client with urine output of 40 mL/hr for the last 2 hours

Question 2

A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best?
 
  a. Ask if the client needs pain medication.
  b. Assess the client's tissue perfusion further.
  c. Document the findings in the client's chart.
  d. Increase the rate of the client's IV infusion.

[akpaschal]

Answer to Question 1

ANS: A
This client has a falling systolic blood pressure, rising diastolic blood pressure, and narrowing pulse pressure, all of which may be indications of the progressive stage of shock. The nurse should assess this client first. The client with the unchanged oxygen saturation is stable at this point. Although the client with a change in pulse has a slower rate, it is not an indicator of shock since the pulse is still within the normal range; it may indicate the client's pain or anxiety has been relieved, or he or she is sleeping or relaxing. A urine output of 40 mL/hr is only slightly above the normal range, which is 30 mL/hr.

Answer to Question 2

ANS: B
Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either. The nurse should not increase the rate of the IV infusion without an order.