Difficulty: Medium
Average Score: 93%
Simulated
A client who has sustained blunt abdominal trauma is admitted to the ICU. Upon assessment the nurse notices the following vital signs: T-99F; HR- 148: RR-38; B/P-60/40. The client is diaphoretic and restless. The following selections are approved by the ICU physician. What would be the PRIORITY nurse's action?
Correct answer
D
Rationale
The client is in hypovolemic shock due to suspected internal bleeding. Lowering the head of the bed improves cerebral perfusion, increasing IV fluids restores intravascular volume, and checking pulse oximetry ensures adequate oxygenation. This is the priority action to stabilize the client.