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Difficulty: EasyPhysiological Adaptation

A practical nurse (PN) is caring for a client admitted with a severe gastrointestinal bleed. The client is restless and reports abdominal cramping rated as 7 on a 0 to 10 scale. Data collection reveals a heart rate of 118 beats/min, a blood pressure of 88/56 mm Hg, and a hemoglobin level of 6.8 g/dL (68 g/L). Which of the following actions should the PN take first?

  1. Notify the registered nurse (RN) immediately about the assessment findings.Answer
  2. B
    Administer the prescribed as-needed (PRN) analgesic for the abdominal cramping.
  3. C
    Reassess the client's vital signs in one hour to monitor for further changes.
  4. D
    Document the hemoglobin level in the electronic health record for the provider to review later.

Answer

The correct action is to immediately notify the registered nurse (RN) about the assessment findings.
The correct answer involves notifying the RN immediately because the client's tachycardia, hypotension, restlessness, and critically low hemoglobin indicate active bleeding and hypovolemic shock. Within the PN scope of practice, escalating critical, life-threatening changes is the absolute top priority.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a history of a gastrointestinal bleed, is restless, has a high heart rate (118 beats/min), low blood pressure (88/56 mm Hg), and a critically low hemoglobin level (6.8 g/dL).
Recognizing abnormal data is the first step in clinical judgment.
2
Identify the underlying complication.
The combination of these findings indicates active bleeding leading to hypovolemic shock.
Connecting the data points helps determine the severity of the situation.
3
Determine the priority nursing action within the PN scope of practice.
The priority is to immediately communicate these critical findings to the RN.
The client requires rapid intervention (such as blood transfusions or intravenous fluids) that the RN must coordinate with the provider.

Key Concept

Prioritization of care in hypovolemic shock
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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