What action should the nurse take for a client with internal bleeding in the intensive care unit (ICU) when an alarm sounds indicating decreased blood pressure?

What action should the nurse take for a client with internal bleeding in the intensive care unit (ICU) when an alarm sounds indicating decreased blood pressure?

• A. Perform an assessment of the client before resuming the change of shift report
• B. Notify the healthcare provider before checking the client
• C. Wait for the next shift to evaluate the situation
• D. Immediately check the laboratory results

Answer: (A)

When a nurse is faced with a situation where an alarm indicates decreased blood pressure in a client with internal bleeding, performing an assessment of the client is the most appropriate action. In critical care settings like the ICU, patient safety and timely intervention are paramount. An alarm signaling decreased blood pressure can indicate a significant and potentially life-threatening change in the client's condition. By assessing the client promptly, the nurse can gather essential data, such as vital signs, level of consciousness, and signs of shock. This assessment helps in determining the severity of the situation and guides further actions, such as notifying the healthcare provider, administering fluids, or implementing emergency interventions as necessary. In this context, it is crucial to prioritize direct patient assessment over other activities, such as resuming a change of shift report or waiting for the next shift. Doing so ensures that the nurse is actively involved in managing the patient's immediate needs and responding to any changes in their clinical status without delay.

When a nurse is faced with a situation where an alarm indicates decreased blood pressure in a client with internal bleeding, performing an assessment of the client is the most appropriate action. In critical care settings like the ICU, patient safety and timely intervention are paramount. An alarm signaling decreased blood pressure can indicate a significant and potentially life-threatening change in the client's condition.

By assessing the client promptly, the nurse can gather essential data, such as vital signs, level of consciousness, and signs of shock. This assessment helps in determining the severity of the situation and guides further actions, such as notifying the healthcare provider, administering fluids, or implementing emergency interventions as necessary.

In this context, it is crucial to prioritize direct patient assessment over other activities, such as resuming a change of shift report or waiting for the next shift. Doing so ensures that the nurse is actively involved in managing the patient's immediate needs and responding to any changes in their clinical status without delay.