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Question

Difficulty: MediumReduction of Risk Potential

Following a total knee arthroplasty, an older adult client's baseline preoperative vital signs were a blood pressure of 132/78132/78 mm Hg and a resting heart rate of 7070 beats per minute. Four hours postoperatively, the practical nurse assesses the client and notes a blood pressure of 102/60102/60 mm Hg, a heart rate of 114114 beats per minute, and a respiratory rate of 2222 breaths per minute. The surgical dressing has a moderate amount of sanguineous drainage. Which action should the nurse take next?

  1. Notify the supervising registered nurse immediately regarding the changes in vital signs.Answer
  2. B
    Document the vital signs and plan to reassess the client in one hour.
  3. C
    Administer the prescribed as-needed oral opioid medication for postoperative pain.
  4. D
    Independently increase the continuous intravenous fluid infusion rate.

Answer

Notify the supervising registered nurse immediately regarding the changes in vital signs.
The correct action is to notify the registered nurse immediately. The client is exhibiting classic early signs of hypovolemic shock—specifically tachycardia and a drop in blood pressure compared to their baseline—along with active bleeding indicated by the sanguineous drainage. These findings require immediate escalation to ensure patient safety and to initiate rapid medical intervention.

Step-by-Step Solution

1
Compare the client's current postoperative vital signs to the preoperative baseline.
The client's blood pressure has decreased significantly (from 132/78132/78 to 102/60102/60 mm Hg), and the heart rate has increased (from 7070 to 114114 beats per minute).
Identifying deviations from the baseline is critical for recognizing early postoperative complications.
2
Analyze the significance of the vital sign trends alongside the physical assessment.
The combination of tachycardia, hypotension, and sanguineous drainage strongly suggests early hypovolemic shock or active bleeding.
Early recognition of shock mechanisms allows for prompt, life-saving interventions before the condition becomes irreversible.
3
Determine the most appropriate and safe nursing action within the practical nurse's scope of practice.
The practical nurse must immediately escalate these critical findings to the registered nurse.
The registered nurse is responsible for performing advanced assessments, contacting the healthcare provider, and initiating complex interventions for shock.

Key Concept

Reduction of Risk Potential: Early Recognition of Shock
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Topics

Reduction of Risk Potential

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