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Difficulty: EasyReduction of Risk Potential

A practical nurse is caring for a client admitted with a gastrointestinal bleed. The client is restless, and their skin is slightly cool to the touch. The client's resting heart rate is 106 beats per minute, and their blood pressure is 108/72 mm Hg. Which of the following is the most appropriate action for the practical nurse to take?

  1. Notify the registered nurse immediately about the client's current status.Answer
  2. B
    Provide a warm blanket to address the client's cool skin.
  3. C
    Document the findings and recheck the vital signs in one hour.
  4. D
    Assign an unlicensed assistive personnel to stay with the client.

Answer

Notify the registered nurse immediately about the client's current status.
The client is exhibiting early signs of hypovolemic shock, including restlessness, cool skin, and tachycardia. It is critical for the practical nurse to recognize these subtle but dangerous changes and immediately escalate the findings to the registered nurse to reduce the risk of a severe complication.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client has restlessness, cool skin, mild tachycardia, and borderline blood pressure, which are collective early indicators of hypovolemic shock.
Recognizing subtle changes from baseline is essential for early intervention and risk reduction.
2
Determine the appropriate nursing intervention within the practical nurse's scope of practice.
The practical nurse must immediately report these acute, unstable changes to the registered nurse.
The registered nurse is responsible for performing advanced assessments and collaborating with the healthcare provider for emergency orders.

Key Concept

Early Recognition of Shock and Escalation
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Topics

Reduction of Risk Potential

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