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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is collecting data on a client who is 2 hours postoperative following an abdominal surgery. The client's vital signs are: heart rate 112 beats/minute, blood pressure 98/62 mm Hg, respiratory rate 18 breaths/minute, and oxygen saturation 97% on room air. The client reports incisional pain of 6 on a 0 to 10 scale and states, 'I feel a little dizzy when I try to sit up.' Which of the following is the priority action for the PN?

  1. Notify the registered nurse (RN) immediately regarding the client's vital signs and dizziness.Answer
  2. B
    Administer the prescribed as-needed (PRN) analgesic to manage the client's postoperative pain.
  3. C
    Document the findings as expected early postoperative changes and continue routine monitoring.
  4. D
    Elevate the head of the bed to a high-Fowler's position to assist with the client's dizziness.

Answer

Notify the registered nurse (RN) immediately regarding the client's vital signs and dizziness.
The client is exhibiting tachycardia, borderline hypotension, and dizziness, which are classic early signs of hypovolemia or hemorrhage following surgery. Within the practical nurse scope of practice, recognizing acute decompensation requires immediate escalation. The priority is to notify the RN so that a comprehensive assessment can be performed and emergency interventions can be initiated promptly.

Step-by-Step Solution

1
Analyze the collected data for abnormalities.
The client has tachycardia (112 beats/min), borderline hypotension (98/62 mm Hg), and orthostatic symptoms (dizziness when sitting up).
Identifying abnormal vital signs is the first step in recognizing clinical deterioration.
2
Correlate the abnormal findings with the clinical context.
In a 2-hour postoperative client, these findings are early indicators of hypovolemia, hemorrhage, or impending shock.
Understanding the significance of the data allows for proper prioritization of care.
3
Determine the most appropriate action within the PN scope of practice.
The PN must immediately escalate these critical findings to the RN.
The RN needs to perform a comprehensive assessment and coordinate potentially life-saving interventions (such as fluid resuscitation) with the healthcare provider.

Key Concept

Recognition of Early Shock and Scope of Practice
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Topics

Physiological Adaptation

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