A resident in an intermediate care facility is recovering from a colonoscopy with multiple… — NCLEX-PN

A resident in an intermediate care facility is recovering from a colonoscopy with multiple polypectomies performed late yesterday afternoon. During the $0600$ rounds, the resident reports feeling "very thirsty and a little dizzy."

Assessment Findings:

Parameter	Current Finding	Baseline
Abdomen	Slightly distended and firm	Soft, non-tender
Blood Pressure	$96/60\text{ mmHg}$	$128/82\text{ mmHg}$
Heart Rate	$112\text{ bpm}$	$74\text{ bpm}$
Respiratory Rate	$22\text{ breaths/min}$	$16\text{ breaths/min}$
Hemoglobin	$10.2\text{ g/dL}$ (at $0500$ )	$14.1\text{ g/dL}$
Hematocrit	$31\%$ (at $0500$ )	$42\%$

Which action is the priority for the practical nurse?

Withhold all oral fluids, position the resident supine with the lower extremities elevated, and immediately alert the charge registered nurse.Answer
B
Provide a small cup of water for the thirst, assist the resident to a sitting position, and reassess the vital signs in one hour.
C
Document the laboratory results in the electronic health record, as the hemoglobin level is above the typical transfusion threshold of $7.0\text{ g/dL}$ .
D
Access the resident's peripheral intravenous line and independently initiate a rapid fluid bolus of normal saline to restore circulatory volume.

Answer

Withhold all oral fluids, position the resident supine with the lower extremities elevated, and immediately alert the charge registered nurse.

The correct action directly addresses the life-threatening complication of postoperative hemorrhage. Thirst, dizziness, a firm abdomen, tachycardia, narrowed pulse pressure, and a nearly

4.0\text{ g/dL}

drop in hemoglobin indicate active internal bleeding and early hypovolemic shock following the polypectomy. The practical nurse must immediately prioritize circulation (positioning), prepare for potential emergency surgery (NPO status), and escalate the critical findings to the registered nurse.

Step-by-Step Solution

Analyze the subjective and objective data in the clinical presentation.

The resident is exhibiting thirst, dizziness, a rigid abdomen, tachycardia, hypotension, and a significant drop in hemoglobin.

Identifying abnormal trends is the first step in recognizing a physiological decline.

Correlate the assessment findings with the recent surgical history.

The recent colonoscopy with polypectomies places the resident at high risk for bowel perforation or postoperative hemorrhage. The data strongly indicates active internal bleeding and early hypovolemic shock.

Connecting the symptoms to the risk factors confirms the severity of the complication.

Determine the appropriate practical nurse scope of practice and priority intervention.

The practical nurse must immediately prioritize safety by withholding fluids (NPO status for potential emergency surgery), optimizing perfusion (elevating legs), and escalating to the registered nurse for advanced resuscitation.

Shock is a medical emergency that requires immediate RN and provider intervention beyond independent practical nurse care.

Key Concept

Early Recognition of Hypovolemic Shock and Hemorrhage

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