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Difficulty: HardReduction of Risk Potential

While conducting a routine postoperative assessment, a practical nurse reviews the status of an adult client who underwent an open cholecystectomy 4 hours ago. The client has a closed-wound drainage system that contains 30 mL of serosanguineous fluid. The client states, "My stomach hurts, and I feel a bit dizzy when I turn over."

A comparison of the client's vital signs reveals the following:

ParameterPreoperative BaselineCurrent Assessment
Blood Pressure134/80 mm Hg102/60 mm Hg
Heart Rate82 bpm118 bpm
Respirations16/min20/min

Based on these findings, what is the priority action for the nurse?

  1. A
    Administer the prescribed PRN analgesic for the reported abdominal pain
  2. B
    Assist the client to an upright sitting position to safely evaluate the dizziness
  3. Notify the registered nurse immediately regarding the assessment findingsAnswer
  4. D
    Empty the drainage system and document the output in the electronic health record

Answer

The correct action is to notify the registered nurse immediately regarding the assessment findings.
The correct answer identifies the need for immediate escalation. The client's significant increase in heart rate and decrease in blood pressure, combined with dizziness, are classic early indicators of hypovolemic shock, likely due to internal hemorrhage. Even though the external drain output is minimal, bleeding may be accumulating internally. The practical nurse must immediately notify the registered nurse so that prompt medical intervention can be initiated.

Step-by-Step Solution

1
Analyze the client's vital signs by comparing the current readings to the preoperative baselines.
The heart rate has increased significantly from 82 to 118 bpm, and the blood pressure has dropped from 134/80 to 102/60 mm Hg.
Identifying trends is essential for recognizing early postoperative complications.
2
Evaluate the client's subjective symptoms in conjunction with the objective data.
The client reports abdominal pain and dizziness when moving.
Dizziness paired with hypotension and tachycardia strongly suggests decreased cerebral perfusion due to hypovolemia.
3
Determine the most appropriate nursing action based on the practical nurse scope of practice and the severity of the findings.
The findings indicate potential internal hemorrhage and shock, which requires immediate escalation.
The practical nurse must promptly report subtle signs of shock to the registered nurse, as the client requires immediate medical intervention that exceeds the practical nurse's scope.

Key Concept

Early recognition of hypovolemic shock and prioritization of escalation.
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Reduction of Risk Potential

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