The client presents to the emergency department following a blow to the abdomen during a baseball game. He is unresponsive with a blood pressure of 82/48 mmHg, heart rate of 118 bpm, a respiratory rate of 18, and an oxygen saturation of 95% on room air. The nurse anticipates taking which action first to treat this patient?

Establish vascular access with large-bore IVs to initiate fluid resuscitation. The patient’s hypotension, tachycardia, and unresponsiveness following a blow to the abdomen indicate the client is likely experiencing hypovolemic shock due to internal bleeding. The nurse must establish vascular access and begin fluid resuscitation to prevent circulatory collapse. The patient may eventually need to be intubated but is currently breathing and maintaining adequate oxygen saturations. The client is likely bleeding internally, so anticoagulant therapy is contraindicated at this time. Although the patient may eventually need an MRI, this is not the appropriate first action by the nurse.

The client presents to the emergency department following a blow ...

Category: Physiological Adaptation
Difficulty: 6

Topics: Cardiovascular Delegation, Prioritization and Leadership Medication and Blood Products Nursing Interventions Routes of Administration

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