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Difficulty: EasyReduction of Risk Potential

While caring for a client who had an open appendectomy 4 hours ago, the practical nurse reviews the client's postoperative status. The client's preoperative heart rate was 76/min and blood pressure was 118/74 mm Hg. Which current finding is the most critical to report to the registered nurse?

  1. Heart rate of 108/min and blood pressure of 100/62 mm HgAnswer
  2. B
    Client report of throbbing pain at the surgical site
  3. C
    Oral temperature of 37.7°C (99.9°F)
  4. D
    Absence of bowel sounds in the lower quadrants

Answer

The most critical finding to report is a heart rate of 108/min and blood pressure of 100/62 mm Hg.
The correct answer identifies a trend of tachycardia (heart rate 108/min) and mild hypotension (blood pressure 100/62 mm Hg). In a postoperative client, these are classic early compensatory signs of hypovolemic shock, often caused by internal bleeding. The practical nurse must recognize this risk potential and report it immediately to the registered nurse to prevent further deterioration.

Step-by-Step Solution

1
Analyze the client's surgical timeline and baseline vital signs.
The client is 4 hours post-open appendectomy with a baseline heart rate of 76/min and blood pressure of 118/74 mm Hg.
Establishing the baseline allows the nurse to identify significant deviations that indicate postoperative complications.
2
Evaluate each assessment finding against expected postoperative norms.
Pain, mild temperature elevation, and absent bowel sounds are expected 4 hours postoperatively. The elevated heart rate and decreased blood pressure are not expected.
Differentiating between benign, expected findings and signs of deterioration is a key practical nursing responsibility.
3
Identify the physiological implication of the abnormal vital signs.
Tachycardia combined with mild hypotension indicates early compensatory hypovolemic shock, likely due to postoperative hemorrhage.
Early recognition of shock allows for prompt intervention before the client becomes hemodynamically unstable.

Key Concept

Early recognition of postoperative hypovolemic shock
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Topics

Reduction of Risk Potential

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