The nurse is caring for a newly

The nurse is caring for a newly admitted 59-year-old male client in the medical surgical unit. History and Physical: The client arrived to the emergency department complaining of a “swelling abdomen,” some shortness of breath, and unexplained bruising. Client states that he was diagnosed with Hepatitis C, but stopped taking the medications because of the side effects. He drinks 5-8 beers per week and smokes tobacco, about 2 packs a week. He denies usage of drugs. New diagnosis of cirrhosis has been confirmed and client has been transferred to medical surgical unit. Nurses’ Notes: 1245: Client is awake but appears lethargic. He is oriented to person, place, and time. Skin is warm and dry upon touch, yellow in color with bruising noted on upper back and left arm. The client states that his skin is “itchy” at times. He also reports of a “swelling abdomen” and shortness of breath. Diminished breath sounds at lung bases bilaterally. Abdomen is distended and slightly tender upon palpation. Last bowel movement 4 hours ago with clay-colored stools. Peripheral pulses are 2+ with capillary refill time of less than 2 seconds. Call light within reach. Will continue to monitor. 1315: Client transferred to radiology unit for abdominal CT scan. 1340: Client returned to unit. No changes since previous assessment noted. 1510: Client rang call light to report new hematemesis. He has not experienced hematemesis before and also reports feeling fait. Emesis in basin revealed large amount of bright red blood. Notified primary health care provider about client’s status. Awaiting orders. Vital signs: 1245: P 90 RR 20 BP 119/70 T: 37.5 C (99.5 F) O2 saturation 98% on room air 1510: P 120 RR 25 BP 90/65 T 37.7 C (99.9 F) O2 saturation 95% on 2L/min via Nasal Cannula Laboratory Results: Image transcription text Sodium (Na) 130 mmol/L 135-145 mmol/L (130 mEq/L) (135-145 mEq/L) Potassium (K) 3.3 mmol/L 3.5-5.0 mmol/L (3.3 mEq/L) (… Show more The nurse has reviewed the Nurses’ Notes and Vital Signs from 1510 Which of the following interventions should the nurse carry out while waiting for orders from the physician? Select all that apply. 1. Elevate the head of bed 2. Maintain NPO status 3. Monitor level of consciousness 4. Prepare for possible blood transfusion 5. Prepare for possible surgery 6. Teach client to perform vasovagal responses 7. Prepare to administer medications to induce vasodilation 8. Monitor blood pressure

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