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Difficulty: MediumReduction of Risk Potential

A client is on bed rest following a left-sided renal biopsy. The client verbalizes feeling lightheaded and reports a dull ache radiating to the left flank. Assessment reveals a pulse of 115 beats per minute and a blood pressure of 98/60 mm Hg. The most recent laboratory results indicate a 4% drop in hematocrit from the pre-procedure baseline. Which intervention should the practical nurse prioritize?

  1. Notify the charge nurse immediately regarding the current assessment data.Answer
  2. B
    Document the findings as expected post-procedure symptoms and reassess in one hour.
  3. C
    Acknowledge the laboratory report and administer the prescribed oral analgesic for the pain.
  4. D
    Independently increase the continuous intravenous fluid infusion rate to stabilize the blood pressure.

Answer

Notify the charge nurse immediately regarding the current assessment data.
The correct action is to immediately report the findings to the charge nurse or provider. The combination of flank pain, lightheadedness, tachycardia, a lower-end blood pressure, and a drop in hematocrit strongly suggests internal bleeding (retroperitoneal hemorrhage) following the renal biopsy. Prompt escalation is necessary to reduce the risk of hypovolemic shock and ensure timely medical intervention.

Step-by-Step Solution

1
Analyze the client's clinical cues, including flank pain, lightheadedness, a heart rate of 115/min, blood pressure of 98/60 mm Hg, and a dropping hematocrit.
These findings collectively indicate a high risk for retroperitoneal hemorrhage, a severe complication of a renal biopsy.
Recognizing the transition from stable to unstable is essential for reducing client risk.
2
Determine the appropriate scope of practice for the practical nurse in this emergency scenario.
The nurse must immediately escalate the findings to the charge nurse or healthcare provider rather than independently initiating advanced medical interventions or dismissing the signs.
Timely communication ensures the client receives rapid medical evaluation and necessary treatments to prevent hypovolemic shock.

Key Concept

Recognizing and escalating signs of post-procedure hemorrhage
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Topics

Reduction of Risk Potential

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