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Difficulty: MediumReduction of Risk Potential

A practical nurse is assessing a client who returned from an esophagogastroduodenoscopy (EGD) with a biopsy 2 hours ago. The client reports a mild sore throat but now states, "My stomach feels really tight and painful." The nurse notes the client's abdomen is firm and distended. The current vital signs are: blood pressure 104/58 mmHg104/58\text{ mmHg}, heart rate 112 beats/min112\text{ beats/min}, respiratory rate 22 breaths/min22\text{ breaths/min}, and temperature 37.4∘C37.4^\circ\text{C} (99.3∘F99.3^\circ\text{F}). Which action should the practical nurse take first?

  1. Notify the registered nurse (RN) immediately about the assessment findings.Answer
  2. B
    Document the vital signs and reassess the client in one hour.
  3. C
    Administer the prescribed PRN analgesic for the client's throat discomfort.
  4. D
    Perform deep abdominal palpation to determine the extent of rigidity.

Answer

Notify the registered nurse (RN) immediately about the assessment findings.
The correct action is to notify the registered nurse immediately. A firm, distended abdomen combined with new-onset severe pain, tachycardia, and borderline hypotension following an EGD with biopsy are classic signs of a perforation. This is a life-threatening emergency that requires immediate advanced assessment by the RN and intervention by the healthcare provider to prevent severe peritonitis and shock.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a firm, distended abdomen, new severe pain, tachycardia (112 beats/min), and borderline low blood pressure (104/58 mmHg) following an invasive gastrointestinal procedure.
Identifying abnormal findings is the first step in recognizing postoperative complications.
2
Correlate the findings with potential procedural complications.
These signs strongly suggest an esophageal or gastric perforation, which can lead to rapid peritonitis and hypovolemic shock.
Understanding the risk factors of an EGD with biopsy helps in anticipating life-threatening events.
3
Determine the appropriate nursing intervention within the LPN scope of practice.
The practical nurse must immediately escalate these critical findings to the RN for advanced assessment and collaboration with the healthcare provider.
Acting within the legal scope of practice ensures client safety during a rapidly evolving emergency.

Key Concept

Recognizing and Escalating Complications of Invasive Procedures
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Topics

Reduction of Risk Potential

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