A nurse in the intensive care unit is caring for a post-transplantation client. This client's first set of vital signs were temperature 94.4° F, pulse 110 beats/min, respirations ventilated at 20 breaths/min, blood pressure 108/64 mm Hg. After 2 hours, the vital signs are temperature 98.4° F, pulse 108 beats/min, respirations ventilated at 20 breaths/min, blood pressure 88/58 mm Hg. Which action by the nurse is most appropriate at this time?
A) Anticipate an order for arterial blood gasses (ABGs).
B) Call the physician to report that the client is still tachycardic.
C) Chart the findings and continue to monitor the client.
D) Prepare to administer vasoconstricting agents.

Question

Quizplus · Accepted Answer

Arterial blood pressure, systemic vascular resistance, and cardiac output usually decrease as the client's temperature rises from the hypothermic state seen initially. Additional support measures are often used during this time of instability, such as vasoactive agents. There is no indication for ABGs and the client is probably tachycardic because of the low blood pressure and physiologic stress of the operation. With any intervention, charting and continued observation are required, but it is not the priority action in this situation.

A Nurse in the Intensive Care Unit Is Caring for a Post-Transplantation