A licensed practical nurse (LPN) is assigned to a client who had a total hip arthroplasty the previous day. Upon entering the room, the LPN observes that the client is pale, restless, and diaphoretic. The electronic health record indicates a morning hemoglobin level of 7.9 g/dL, which is a significant decrease from the post-operative value of 10.8 g/dL. Current vital signs include a heart rate of 116 beats per minute and a blood pressure of 90/56 mm Hg. What is the most appropriate initial action for the LPN to take?
- AIncrease the rate of the continuous intravenous fluid infusion to improve blood pressure.
- BAdminister the client's scheduled oral analgesic to promote comfort and reduce restlessness.
- Promptly notify the supervising registered nurse about the client's current status.Answer
- DRecord the vital signs and hemoglobin drop in the chart for the provider to review during rounds.
Answer
The most appropriate initial action is to promptly notify the supervising registered nurse about the client's current status.
The client is exhibiting classic signs of hypovolemic shock (tachycardia, hypotension, restlessness, diaphoresis) and internal bleeding (dropping hemoglobin) following major surgery. The LPN's priority action when identifying an unstable, deteriorating client is to immediately notify the supervising registered nurse or healthcare provider so that life-saving interventions can be initiated.
Step-by-Step Solution
Key Concept
Recognizing early signs of shock and escalating critical findings
Estimated Time:1m 0s