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    Ati ew n300 med surg final proctored exam

    The nurse is caring for a patient in hypovolemic shock as a result of penetrating thoracic trauma. The patient has received 3L of lactated ringers' solution (LR), 2 units of packed red blood cells (PRBC's), 1 unit of fresh frozen plasma (FFP), and 1 unit of platelets. Which assessment finding should the nurse report to the provider immediately?

    Explanation & Rationale

    A. Heart rate of 105 bpm is slightly elevated but may be expected during recovery from shock. B. Crackles at bilateral bases suggest possible fluid overload or pulmonary edema, which is a serious complication that requires immediate intervention. C. Pulse oximetry of 95.9% is within acceptable limits and not concerning. D. Blood pressure of 102/78 mmHg is stable and acceptable in this context.

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