A patient, being treated for hypovolemia because of traumatic injuries, has a blood pressure of 110/60 mmHg. Which of the following should the nurse do to validate this clinical finding?
1. evaluate hemoglobin level
2. assess neck veins and urine output
3. check serum potassium level
4. measure oxygen saturation with oximetry
2
Rationale: Peripheral vasoconstriction, a compensatory mechanism, may artificially elevate blood pressure readings even though central arterial pressures are low in the patient being treated for hypovolemia because of traumatic injuries. To prevent misdiagnosis by focusing on one symptom while ignoring others, the nurse should monitor the trauma patient's blood pressure and at the same time assess neck veins, level of consciousness, and urine output. The hemoglobin level may or may not be a reliable source for fluid status. Checking the serum potassium level will not provide adequate information about the patient's fluid status. The oxygen saturation measurement through oximetry will not provide information about the patient's fluid status.
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