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

question 9

Multiple Choice

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.

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