Examkin

Question

Difficulty: HardData Collection Techniques

A practical nurse (PN) is collecting focused physical data for a 5252-year-old client who underwent an open bowel resection 1212 hours ago. The client's admission baseline vital signs were: blood pressure 138/84138/84 mm Hg, heart rate 7878 beats/min, and respiratory rate 1616 breaths/min. During the current rounds, the PN notes a blood pressure of 106/64106/64 mm Hg, a heart rate of 118118 beats/min, a respiratory rate of 2222 breaths/min, and pale, mildly clammy skin. The client states, "My pain is manageable, but I feel a bit dizzy." Which action should the PN take based on this data interpretation?

  1. A
    Document the vital signs as an expected postoperative response and recheck the client during the next scheduled round in 44 hours.
  2. B
    Administer a prescribed as-needed antiemetic or analgesic to address the client's dizziness and maintain postoperative comfort.
  3. Recognize these findings as potential early indicators of shock and immediately report them to the registered nurse.Answer
  4. D
    Initiate a comprehensive, independent cardiovascular and neurological assessment to formulate a new diagnostic plan of care.

Answer

The correct action is to recognize the data as indicators of shock and immediately report them to the registered nurse for rapid intervention.
The correct action is to recognize the vital sign trends (tachycardia, relative hypotension, tachypnea) combined with pale, clammy skin and dizziness as subtle, early signs of hypovolemia or hemorrhagic shock. The PN's scope of practice requires interpreting these abnormal focused data collection findings and escalating them immediately to the registered nurse (RN) or provider for rapid intervention.

Step-by-Step Solution

1
Compare the current vital signs and physical data to the client's admission baseline.
The blood pressure has dropped significantly, heart rate has increased to tachycardia, respiratory rate has increased, and skin is pale and clammy.
Establishing a trend is essential in data collection to identify acute physiological changes.
2
Interpret the combined significance of the subjective and objective data.
The combination of relative hypotension, tachycardia, tachypnea, dizziness, and clammy skin points to decreased cardiac output.
These are classic early indicators of hypovolemic or hemorrhagic shock in a postoperative client.
3
Determine the appropriate PN action based on the scope of practice.
The PN must immediately escalate these critical findings to the RN.
While the PN can collect focused data, a rapidly deteriorating client requires an RN's comprehensive assessment and immediate medical intervention.

Key Concept

Interpreting Borderline Vital Signs and Postoperative Shock Trends
Estimated Time:1m 30s
Rate this question

Topics

Data Collection Techniques

More questions from this topic