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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is monitoring a 68-year-old client who had a left total hip arthroplasty earlier today. The client suddenly becomes restless and confused. The PN observes a widening circle of bright red sanguineous drainage on the surgical dressing. The client's heart rate has increased from 84 to 108 bpm, and blood pressure has changed from 122/76 to 104/88 mmHg. Identify the immediate actions the PN must include in the care of this client. Select all that apply.

  1. Reinforce the surgical dressing with sterile gauze pads and apply manual pressureAnswer
  2. B
    Conclude the vital signs are within acceptable postoperative limits and continue routine monitoring
  3. C
    Administer the prescribed as-needed (PRN) oral oxycodone for postoperative discomfort
  4. Immediately notify the registered nurse (RN) of the changes in the client's statusAnswer
  5. E
    Reorient the client and attribute the confusion to hospital-induced delirium common in older adults
  6. Verify the patency of the client's peripheral intravenous (IV) catheterAnswer

Answer

The correct actions are to reinforce the dressing with manual pressure, notify the RN immediately, and verify IV patency.
The client is demonstrating early signs of hypovolemic shock due to acute hemorrhage, evidenced by active bleeding, tachycardia, a significantly narrowed pulse pressure, and altered mental status. The priority actions are to apply manual pressure to the bleeding site to stem blood loss, ensure the IV line is patent for immediate fluid or blood product resuscitation, and immediately notify the RN to escalate the client's level of care.

Step-by-Step Solution

1
Analyze the clinical data provided in the scenario.
The client exhibits a narrowed pulse pressure (16 mmHg), tachycardia, acute confusion, and active surgical site bleeding, which indicate early hypovolemic shock.
Recognizing early physiological decompensation is required to properly prioritize emergency care.
2
Evaluate the correct interventions for acute hemorrhage.
The immediate physical priorities are to control the bleeding by applying pressure and to ensure vascular access for fluid resuscitation.
These actions directly support the client's circulation, which is the primary ABC priority in this scenario.
3
Determine the appropriate escalation within the PN scope of practice.
The PN must immediately notify the RN so that advanced medical interventions can occur.
The RN is responsible for initiating provider communication and overseeing advanced therapies like blood product administration.

Key Concept

Early Recognition and Prioritization of Hypovolemic Shock
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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