A patient with a history of anemia who is 3 days postop is admitted to the unit for rehabilitation after a right ORIF
Assessment reveals fatigue, pallor, pulse 102, blood pressure 100/51, respirations 20, and temperature 99° F. The nurse's immediate action should be to call the physician to obtain
a. stool tests for guaiac.
b. Hgb and Hct measurements.
c. a platelet count.
d. an order for hypertonic fluids.
ANS: B
Given the patient's symptoms, and because the individual is postop, the risk for bleeding exists, and measurement of the hemoglobin and hematocrit is a good means of detecting this.
Stool tests for guaiac are not indicated unless GI bleeding is suspected.
A platelet count would be indicated, but not before measurement of Hgb and Hct, which are the best indicators of bleeding.
Hypertonic fluids are not indicated, although isotonic fluids may be indicated.
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