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Difficulty: MediumPhysiological Adaptation

A 78-year-old client is recovering in the surgical unit six hours after a transurethral resection of the prostate (TURP). The practical nurse (PN) observes that the client is newly restless and asking repetitive questions about his location. Vital signs reveal a heart rate of 112 beats/min and a blood pressure of 98/62 mm Hg. The client's preoperative vital signs were a heart rate of 76 beats/min and a blood pressure of 138/82 mm Hg. Which action is the priority for the PN?

  1. A
    Reorient the client to the surroundings and provide a quiet environment
  2. B
    Document the findings in the medical record and reassess the client in one hour
  3. Notify the registered nurse immediately regarding the changes in vital signs and cognitionAnswer
  4. D
    Administer the prescribed as-needed analgesic to manage the client's restlessness

Answer

The priority action is to notify the registered nurse immediately regarding the changes in vital signs and cognition.
The correct answer requires immediate escalation to the registered nurse. The client's new-onset confusion, restlessness, tachycardia, and drop in blood pressure are classic early indicators of hypovolemic shock, a serious potential complication of a transurethral resection of the prostate (TURP) due to bleeding. The practical nurse must recognize these systemic changes as a medical emergency and immediately communicate the findings so that life-saving interventions (such as IV fluids or blood products) can be initiated.

Step-by-Step Solution

1
Analyze the client's current vital signs and mental status against the baseline preoperative data.
The heart rate has significantly increased (tachycardia), blood pressure has decreased (hypotension), and mental status has acutely changed (restlessness, confusion).
Comparing current assessment data to baseline is essential to identify acute physiological deterioration.
2
Correlate the systemic findings with potential postoperative complications for a TURP procedure.
The combination of symptoms strongly suggests decreased tissue perfusion and early hypovolemic shock, likely resulting from postoperative hemorrhage.
Understanding the physiological meaning of the data guides clinical prioritization and safety.
3
Determine the priority nursing action within the PN scope of practice.
The priority is to immediately report the unstable findings to the supervising registered nurse (RN) or provider for advanced assessment and intervention.
A client exhibiting signs of shock is hemodynamically unstable and requires immediate escalation of care.

Key Concept

Recognizing early signs of hypovolemic shock and prioritizing escalation of care
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Topics

Physiological Adaptation

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