13. An elderly client with a history of congestive heart failure (CHF) and hypertension (HTN) had a hip prosthesis inserted. Blood pressure is 80/50 mm Hg; heart rate is 80; urine output is 15 mL during the last hour. The most appropriate nursing action would be to:
. Document these findings and continue to monitor vital signs.
. Give NS 250 mL over 15 minutes, check vital signs (VS) and lung sounds.
. Check Na+ and K+ levels before selecting IV fluids.
. Give 1 L lactated Ringer's as fast as possible, then check VS, neck circumference, and lab reports.
Test-Taking Tip
Analysis of the data is consistent with shock. Choose an action that is safest for the older adult.
Content Area: Geriatrics, Cardiovascular; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Fluid and Electrolyte Imbalances
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Answer 1 is incorrect because the findings for BP and urine output are not normal. They indicate a client who has volume depletion, and an intervention is needed. Answer 2 is correct because the low blood pressure and low urine output suggest fluid volume deficit, which should be treated with normal saline. Although it is usual to expect tachycardia in clients with hypotension, it is likely that the CHF and HTN are being managed with a beta blocker, which prevents the reflex tachycardia. Due to the client's age and heart problems, a small dose of normal saline should be given and evaluated. Answer 3 is incorrect because, while it is good to know these laboratory values, it is not necessary before starting some normal saline to correct the hypotension. Answer 4 is incorrect because the nurse needs to use caution when administering rapid rates of IV fluids to elderly clients with CHF.