A 35-year-old patient is brought to the emergency department following a motor vehicle accident with significant blood loss. The patient's blood pressure is 80/50 mmHg, heart rate is 120 bpm, and urine output has decreased to 15 mL/hr. Which nursing intervention should be the priority?

This patient presents with classic signs of hemorrhagic (hypovolemic) shock following a traumatic event. The vital signs—blood pressure 80/50 mmHg (hypotension) and heart rate 120 bpm (tachycardia)—indicate a compensatory response to significant intravascular volume loss. The decreased urine output of 15 mL/hr (oliguria) is a critical sign of poor end-organ tissue perfusion, confirming that the body is shunting blood away from the kidneys to preserve flow to the heart and brain. In traumatic cardiac arrest and peri-arrest states, the immediate focus must be on addressing the underlying cause of the shock, which is hypovolemia .

The HOTT protocol (Hypovolaemia, Oxygenation, Tension pneumothorax, Tamponade) identifies hypovolaemia as a primary reversible cause requiring immediate treatment . In the hierarchy of trauma care, restoring circulating volume takes precedence to prevent progression to decompensated shock and cardiac arrest. The best available evidence for emergency nursing care emphasizes that early recognition and prompt fluid resuscitation are the cornerstones of management, with the nurse playing a central role in initiating these time-sensitive interventions . Evidence-based protocols for acute hemorrhage stress that stabilizing hemodynamics through immediate, effective fluid resuscitation is the critical first step to prevent complications and improve outcomes .

Establishing large-bore IV access for fluid resuscitation (Option 4) is the correct priority.
The Guidelines for Essential Trauma Care emphasize that initial resuscitation requires the immediate establishment of intravenous access to replace lost intravascular volume . Without venous access, no fluids or blood products can be administered, making this the foundational intervention upon which all other resuscitative efforts depend. A large-bore catheter (e.g., 14- or 16-gauge) is essential because it allows for the rapid infusion of warmed crystalloids or blood products, which is necessary to counteract the profound hypovolemia indicated by the patient's hypotension and reflex tachycardia.

While the other options represent valid nursing actions, they are secondary to volume restoration in the sequence of trauma resuscitation:

• Administering oxygen (Option 1) addresses hypoxia, which is a component of the HOTT protocol . However, oxygen delivery to tissues is critically dependent on circulating hemoglobin and blood volume. Supplemental oxygen will be ineffective if the vascular space is empty, as there is insufficient blood to carry the oxygen to the tissues.


• Inserting a urinary catheter (Option 2) is essential for accurate monitoring of urine output as a marker of renal perfusion and resuscitation adequacy. However, it is a monitoring tool, not a resuscitative intervention. The priority is to treat the cause of the oliguria (hypovolemia) rather than to simply measure it.


• Elevating the legs 30 degrees (Option 3) is a passive leg raise maneuver that can transiently increase venous return by autotransfusing blood from the lower extremities. However, this is a temporary measure that provides a small, non-sustained volume bolus. It is not a substitute for definitive volume replacement through IV access and can delay life-saving fluid administration .

The synthesis of evidence confirms that the nurse's immediate priority is to facilitate the rapid infusion of fluids by securing IV access, as this directly targets the pathophysiological mechanism of hypovolemic shock and is the intervention most likely to reverse the patient's hemodynamic instability .