Reference no: EM133712463

Question

Nurse's Notes The nurse on the surgical unit receives a client from the Post Anesthesia Care Unit. Vital Signs 1000: 1020: The client is 2 hours postoperative from an open right hemicolectomy. Estimated blood loss (EBL) in surgery was 380 mL. Client is awake, but drowsy. Skin warm and dry. Radial and pedal pulses present and 2+ bilaterally. Lungs clear, oxygen on at 2L per nasal cannula (O2 2L/NC). Abdomen is firm, bowel sounds are absent throughout. Abdominal dressing dry and intact. Client reports pain 3/10. An 18 gauge peripheral vascular device present to left forearm infusing normal saline at 70 mL/hr. Site without redness, dressing intact. Client is resting in bed with head of bed elevated 15 degrees. Spouse at bedside. Client's spouse requests assistance in room. Client appears anxious and distressed. Client's skin is pale, cool and clammy. Client reports, "I don't know what's wrong, but I feel really dizzy and lightheaded!" Radial pulses are weak. Abdomen is firm and distended. Abdominal dressing dry and intact. Client reports abdominal pain at 8/10. The nurse responds to a call for assistance from the client's spouse, assesses the client and obtains vital signs. Based on the assessment findings, which intervention.