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    Ati Nurs 223 W26 Med Surg Proctored Exam 2
    Select All That Apply

    A nurse is caring for a client in the emergency department. Exhibits A nurse has received report about a client being admitted to the medical- surgical unit. Click to highlight the findings in the transfer report that require immediate action by the nurse when the client arrives. The client complains of fatigue, vertigo, and shortness of breath with daily activities. Current vital signs are: blood pressure 86/46 mm Hg, pulse rate 100/min, respiratory rate 28/min. Oxygen saturation 94% on 2 L via nasal cannula. Client has an 18 g capped IV in the right antecubital space. There is a new prescription for 0.9% sodium chloride at 125 mL/hr. There is also a prescription for the transfusion of 2 units of packed RBCS: the first unit has been ordered from the blood bank. Oxygen is to be titrated to maintain an oxygen saturation of 92%.

    Explanation & Rationale

    Rationale: Shortness of breath with daily activities requires follow up as it can lead to life threatening hypoxemia. Blood pressure of 86/46mmHg is very low and can lead to organ failure. Intervention is therefore a priority.

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