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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is evaluating a client who is 6 hours post-operative following an abdominal hysterectomy. The client reports feeling slightly dizzy, exhausted, and having mild abdominal cramping. During the data collection, the PN notes a heart rate of 112 beats/min, a blood pressure of 98/60 mm Hg, and a fully saturated perineal pad with bright red blood. The surgical abdominal dressing remains clean and dry. Which action should the PN take first?

  1. Notify the registered nurse (RN) immediately about the bleeding and vital signs.Answer
  2. B
    Reassess the client's blood pressure and heart rate in 30 minutes.
  3. C
    Elevate the head of the client's bed to a high-Fowler's position.
  4. D
    Provide the prescribed PRN oral analgesic for the abdominal cramping.

Answer

The correct action is to notify the registered nurse (RN) immediately about the bleeding and vital signs.
The client is demonstrating signs of active hemorrhage and early hypovolemic shock, including tachycardia, borderline hypotension, dizziness, and heavy vaginal bleeding. In an acute deterioration involving circulation, the priority action within the practical nurse's scope of practice is to immediately notify the supervising registered nurse or healthcare provider to initiate emergency interventions.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client has tachycardia, borderline hypotension, dizziness, and heavy vaginal bleeding.
Identifying deviations from normal post-operative recovery is the first step in clinical judgment.
2
Correlate the findings with potential complications.
The combination of these signs indicates active hemorrhage and early hypovolemic shock.
Recognizing the physiological adaptation to blood loss is critical for patient safety.
3
Determine the priority nursing intervention within the PN scope of practice.
The PN must immediately notify the RN or healthcare provider.
Active hemorrhage is a life-threatening circulation issue that requires rapid medical intervention beyond the independent scope of the practical nurse.

Key Concept

Recognizing postoperative hemorrhage and prioritizing circulation interventions
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Topics

Physiological Adaptation

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