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Question

Difficulty: MediumReduction of Risk Potential

A practical nurse is assessing a client who underwent an open bowel resection 1212 hours ago. Which clinical finding should the nurse identify as the highest priority to report to the registered nurse?

  1. A resting heart rate of 114114 beats per minute and a blood pressure of 98/6298/62 mm HgAnswer
  2. B
    Client report of throbbing abdominal pain rated as a 77 on a 00 to 1010 scale
  3. C
    A morning serum hemoglobin result of 11.211.2 g/dL (112112 g/L)
  4. D
    A new prescription for an intravenous push antiemetic to treat nausea

Answer

The correct answer is the finding of a resting heart rate of 114 beats per minute and a blood pressure of 98/62 mm Hg.
The correct answer is the elevated heart rate and lowered blood pressure, as these are classic signs of early hypovolemic shock. In a client who is 1212 hours postoperative, these borderline vital signs strongly suggest internal hemorrhage or severe fluid volume deficit. This is a life-threatening complication requiring immediate escalation to the registered nurse for assessment, fluid resuscitation, and provider notification.

Step-by-Step Solution

1
Analyze the client's timeframe and surgical procedure.
The client is 1212 hours post-open bowel resection, placing them in a critical window for postoperative hemorrhage and fluid shifts.
Identifying the postoperative timeframe highlights the most likely physiological risks.
2
Evaluate the vital signs option against baseline expectations.
Tachycardia (heart rate of 114114) combined with borderline hypotension (blood pressure of 98/6298/62) are classic indicators of early hypovolemic shock.
Vital signs provide objective data about the client's circulatory status.
3
Apply the ABC (Airway, Breathing, Circulation) prioritization framework to compare the options.
Circulatory compromise (shock) takes priority over expected postoperative pain (comfort), slightly abnormal but stable labs, and scope of practice limitations regarding medication administration.
The ABC framework ensures life-threatening physiological needs are addressed first.
4
Select the most life-threatening finding.
The vital signs indicating early shock require immediate registered nurse notification for prompt fluid resuscitation.
Delaying treatment for shock can result in irreversible organ damage or death.

Key Concept

Reduction of Risk Potential: Prioritization of Postoperative Complications
Estimated Time:1m 0s
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Topics

Reduction of Risk Potential

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