A practical nurse is collecting vital signs for a client who is hours post-operative following an open cholecystectomy. The client's current vital signs are a blood pressure of mm Hg, a heart rate of beats/minute, and respirations of breaths/minute. The client states, "I feel a little dizzy and weak." Which action should the practical nurse take first?
- Notify the registered nurse immediately about the client's vital signs and symptoms.Answer
- BAssist the client into a high-Fowler's position to promote post-operative comfort.
- CAsk the client to rate their pain and administer the prescribed analgesic.
- DDocument the vital signs in the electronic health record and continue routine monitoring.
Answer
Notify the registered nurse immediately about the client's vital signs and symptoms.
The correct action is to immediately notify the registered nurse. The client's tachycardia, hypotension, and dizziness hours after major abdominal surgery are early signs of hypovolemic shock or internal bleeding. Prompt escalation is necessary to initiate life-saving interventions such as fluid resuscitation or returning to the operating room.
Step-by-Step Solution
Key Concept
Early Recognition and Escalation of Hypovolemic Shock