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Difficulty: MediumReduction of Risk Potential

An LPN/LVN is assigned to care for a client recovering from a partial colectomy performed earlier in the day. The client's current vital signs reveal a heart rate of 114114 beats/minute, a blood pressure of 96/5896/58 mm Hg, and a respiratory rate of 2222 breaths/minute. Simultaneously, the electronic health record alerts the nurse to a newly resulted serum hemoglobin level of 7.37.3 g/dL. Based on these clinical findings, what is the most appropriate initial action?

  1. Immediately alert the registered nurse about the client's vital signs and the recent blood work.Answer
  2. B
    Document the laboratory results in the chart and plan to pass the information along during the upcoming shift change.
  3. C
    Continue the routine postoperative assessments since the client's systolic blood pressure has not dropped to a critical level.
  4. D
    Prepare the intravenous tubing and independently initiate a transfusion of packed red blood cells.

Answer

Immediately alert the registered nurse about the client's vital signs and the recent blood work.
The correct response demonstrates the practical nurse's ability to identify a high-risk postoperative complication (hemorrhage leading to hypovolemic shock) by recognizing the combination of tachycardia, borderline hypotension, and a critical hemoglobin level. Immediate escalation to the registered nurse is the safest and most appropriate action within the LPN/LVN scope of practice to reduce client risk.

Step-by-Step Solution

1
Analyze the vital signs in the context of the surgical procedure.
The heart rate of 114114 beats/minute and blood pressure of 96/5896/58 mm Hg indicate tachycardia and borderline hypotension, which are early signs of compensatory shock following a major abdominal surgery.
Recognizing subtle shifts in vital signs is essential for early identification of postoperative hemorrhage.
2
Evaluate the newly resulted laboratory value.
A hemoglobin level of 7.37.3 g/dL is critically low and corroborates the vital sign trends, pointing toward active bleeding.
Correlating clinical presentation with diagnostic data confirms the severity of the client's condition.
3
Determine the appropriate nursing intervention within the LPN/LVN scope of practice.
The nurse must escalate the findings to the registered nurse or healthcare provider immediately.
Practical nurses must recognize complications and escalate care for interventions that fall outside their scope, such as administering blood products or altering the medical plan of care.

Key Concept

Early recognition of hypovolemic shock and appropriate escalation within the practical nursing scope of practice.
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Reduction of Risk Potential

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