The nurse is caring for a renal transplant recipient in the post-anesthesia care unit
Blood pressure is 125/70 mm Hg; heart rate is 115 beats/min; respiratory rate is 24 breaths/min; oxygen saturation (SpO2) is 95% on 3 L/min of oxygen via nasal cannula, temperature is 97.8° F, and the central venous pressure (CVP/RAP) is 2 mm Hg. What is the best action by the nurse? a. Administer fluid replacement therapy; monitor intake and output closely.
b. Increase supplemental oxygen to 100% non-rebreather mask; notify physician.
c. Apply thermal warming blanket; administer all fluids through warming device.
d. Assess the patient for pain; administer pain medications as ordered.
A
Fluid replacement therapy is a priority in a postoperative renal transplant patient with a CVP of 2 mm Hg and elevated heart rate. An oxygen saturation of 95% on 3 L/min via cannula is an acceptable value. The patient is normothermic; application of active warming measures is not indicated. Although pain assessment is an important part of postoperative nursing care, it is not the priority in this scenario.
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