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Question

Difficulty: MediumReduction of Risk Potential

A practical nurse is caring for a client admitted with severe gastroenteritis and prolonged diarrhea. The client's admission blood pressure was 118/76118/76 mm Hg with a heart rate of 8484 beats per minute. Four hours later, the nurse notes the blood pressure is 100/62100/62 mm Hg and the heart rate is 112112 beats per minute. The client's oral mucosa is dry. Which of the following actions should the practical nurse take first?

  1. A
    Increase the rate of the continuous intravenous (IV) fluid infusion to restore blood volume
  2. Notify the registered nurse (RN) immediately regarding the changes in vital signsAnswer
  3. C
    Document the findings and encourage the client to increase oral fluid intake
  4. D
    Administer the prescribed as-needed (PRN) antidiarrheal medication to prevent further fluid loss

Answer

Notify the registered nurse (RN) immediately regarding the changes in vital signs
The client's shifting vital signs (tachycardia and hypotension) combined with a history of severe diarrhea indicate the onset of hypovolemic shock. Because this is a potentially life-threatening complication that requires advanced clinical assessment and medical interventions (such as fluid boluses), the practical nurse must prioritize immediately escalating these findings to the registered nurse.

Step-by-Step Solution

1
Analyze the client's vital sign trends over the past four hours.
The heart rate increased from 8484 to 112112 beats per minute (tachycardia), and the blood pressure decreased from 118/76118/76 to 100/62100/62 mm Hg (hypotension).
Comparing current vital signs to baseline is essential for identifying physiological deterioration.
2
Correlate the vital sign changes with the client's admitting diagnosis.
The client has severe gastroenteritis with prolonged diarrhea, placing them at high risk for significant fluid volume deficit.
Understanding the underlying pathology helps anticipate complications such as severe dehydration and hypovolemia.
3
Determine the priority nursing intervention based on the practical nurse scope of practice.
The practical nurse must immediately communicate these findings to the registered nurse.
The vital sign trends indicate early hypovolemic shock, which requires advanced assessment, provider notification, and potentially rapid fluid resuscitation that exceeds the practical nurse's independent scope.

Key Concept

Recognition of early hypovolemic shock and appropriate escalation of care.
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Topics

Reduction of Risk Potential

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