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Difficulty: HardReduction of Risk Potential

A practical nurse (PN) is caring for a client who is 4 hours postoperative following an open reduction and internal fixation (ORIF) of a fractured right femur. The client reports increasing incisional pain. The PN obtains the following vital signs: temperature 98.8°F (37.1°C), heart rate 110 beats/min, respiratory rate 20 breaths/min, and blood pressure 102/64 mm Hg. Which action should the PN take first?

  1. A
    Document the vital signs as a normal physiological response to postoperative pain.
  2. Notify the registered nurse immediately to evaluate the client for potential hypovolemia.Answer
  3. C
    Bypass the medication barcode scanning system to expedite the delivery of an oral analgesic.
  4. D
    Administer a prescribed intravenous push (IVP) opioid analgesic to provide rapid relief.

Answer

Notify the registered nurse immediately to evaluate the client for potential hypovolemia.
Following a major orthopedic surgery such as a femur fracture repair, clients are at a high risk for significant blood loss. A heart rate of 110 beats/min combined with a blood pressure of 102/64 mm Hg, particularly when the client is experiencing pain (which typically elevates blood pressure), represents borderline vital signs that strongly indicate early hypovolemic shock. The practical nurse must immediately escalate these findings to the registered nurse for comprehensive assessment and intervention.

Step-by-Step Solution

1
Analyze the client's surgical history and postoperative timeframe.
The client had a femur ORIF 4 hours ago, a procedure associated with significant vascularity and a high risk of postoperative blood loss.
Identifying the client's specific surgical risks helps prioritize potential physiological complications.
2
Evaluate the current vital signs against expected physiological responses.
The heart rate is elevated (110 beats/min) and the blood pressure is on the lower end (102/64 mm Hg).
Pain typically causes an increase in both heart rate and blood pressure. A low-normal blood pressure accompanied by tachycardia is a red flag for volume depletion.
3
Determine the appropriate scope of practice and necessary escalation.
The practical nurse must report these early signs of potential hypovolemic shock directly to the registered nurse.
The RN is responsible for performing a comprehensive assessment to diagnose hemorrhage and coordinating appropriate medical interventions with the provider.

Key Concept

Early recognition of hypovolemic shock and appropriate escalation within the practical nursing scope of practice.
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Reduction of Risk Potential

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