RN Nursing · Cardiovascular Assessment · Practice question
A nurse is caring for a client in a telemetry unit. The client presented with symptoms of weakness and fatigue. The nurse is monitoring the client's vital signs and laboratory results closely. Which of the following nursing actions are anticipated and which are contraindicated for this client?
Nurse’s Notes
1530
Client reports increased fatigue over the past few days, denies chest pain, but has difficulty catching breath after minimal exertion.
Skin appears pale and cool to touch.
Requires assistance for repositioning in bed.
2200
Client's condition remains stable, but reports occasional palpitations.
No acute distress noted, vital signs monitored every hour.
Laboratory Results
| Vital Sign | 1530 | 2200 |
| Temperature | 36.7°C (98.1°F) | 36.8°C (98.2°F) |
| Heart Rate | 112/min | 105/min |
| Respiratory Rate | 22/min | 21/min |
| Blood Pressure | 90/60 mm Hg | 88/58 mm Hg |
| Oxygen Saturation | 92% on room air | 97% on room air |
Answer & explanation
Correct:
This client presents with tachycardia, hypotension (blood pressure 90/60 and trending downward), low oxygen saturation of 92%, pallor, fatigue, and dyspnea on minimal exertion — a clinical picture consistent with anemia or early hemodynamic compromise. Placing the client in high Fowler's position is anticipated because it reduces the work of breathing and improves respiratory mechanics for someone who is dyspneic. Administering oxygen at 2 L/min via nasal cannula is anticipated because the initial saturation of 92% is below the acceptable threshold and supplemental oxygen is a standard, low-risk first response. Initiating a rapid IV fluid bolus of normal saline is anticipated because the client is hypotensive and tachycardic, indicating volume depletion that warrants prompt fluid resuscitation. Preparing for vasopressors is contraindicated at this stage; vasopressors are reserved for refractory shock after adequate volume replacement has been attempted, and initiating them before fluid resuscitation is not indicated and could cause unnecessary harm. Starting vasopressors without first correcting volume status in this context would be premature and potentially dangerous. The downward blood pressure trend warrants monitoring and fluid, not immediate vasopressor therapy, making that action contraindicated in the current clinical picture.
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