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Question

Difficulty: EasyPhysiological Adaptation

A practical nurse (PN) is reviewing the electronic health records of four assigned clients before beginning morning rounds. Which client should the PN see first?

  1. A client who is 4 hours postoperative following an appendectomy and has a blood pressure of 90/58 mm Hg and a heart rate of 118/minAnswer
  2. B
    A client with a fractured femur who is requesting immediate medication for a pain level of 8 on a 0 to 10 scale
  3. C
    A client recovering from a total hip arthroplasty who has an abduction pillow placed between the lower extremities
  4. D
    A client receiving continuous intravenous fluids whose most recent serum potassium level was 4.0 mEq/L (4.0 mmol/L)

Answer

The client who is 4 hours postoperative following an appendectomy and has a blood pressure of 90/58 mm Hg and a heart rate of 118/min.
The client with a blood pressure of 90/58 mm Hg and a heart rate of 118/min is demonstrating early signs of hypovolemic shock, a critical and potentially life-threatening complication of surgery. This circulatory instability takes the highest priority and requires immediate data collection and reporting to the registered nurse.

Step-by-Step Solution

1
Analyze the vital signs of the postoperative client with a blood pressure of 90/58 mm Hg and heart rate of 118/min.
Identified as early signs of hypovolemic shock (hypotension and tachycardia), a critical circulatory complication.
Recognizing signs of shock immediately is essential for preventing rapid clinical deterioration.
2
Evaluate the condition of the client with a fractured femur reporting severe pain.
Identified as a high-priority comfort need, but not an immediate life-threatening physiological emergency.
Using the ABC (Airway, Breathing, Circulation) framework, circulation takes precedence over pain.
3
Review the status of the client with a total hip arthroplasty utilizing an abduction pillow.
Identified as an expected and appropriate postoperative positioning intervention.
Abduction pillows are standard care to prevent hip dislocation after arthroplasty and do not require troubleshooting.
4
Assess the potassium level of the client receiving intravenous fluids.
Identified a laboratory value of 4.0 mEq/L, which is within the normal expected range.
Normal laboratory values do not indicate an acute or unstable physiological problem.
5
Compare all client scenarios to determine the highest overall priority for the nurse.
The postoperative client with signs of shock is selected as the top priority.
Acute circulatory compromise presents the most immediate risk to client safety and requires the most urgent assessment.

Key Concept

Prioritization using the ABCs framework and early recognition of hypovolemic shock.
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Topics

Physiological Adaptation

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