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Difficulty: HardReduction of Risk Potential

A client is 6 hours postoperative following a partial colectomy. The client's indwelling urinary catheter has drained 20 mL over the past hour. Current vital signs reveal a heart rate of 112 beats/minute and a blood pressure of 102/64 mm Hg. A recently resulted hemoglobin level is 7.6 g/dL (76 g/L). The client also reports incisional pain rated 6 on a 0-to-10 scale. Which action is the priority for the practical nurse?

  1. Notify the registered nurse immediately regarding the combination of clinical and laboratory findings.Answer
  2. B
    Administer the prescribed as-needed analgesic to address the client's reported incisional pain.
  3. C
    Document the current vital signs and continue to monitor the hourly urine output closely.
  4. D
    Contact the laboratory to request a repeat blood draw to verify the abnormally low hemoglobin result.

Answer

The priority action is to immediately notify the registered nurse about the combination of oliguria, tachycardia, hypotension, and critically low hemoglobin.
The client is exhibiting classic signs of hypovolemic shock due to postoperative hemorrhage, indicated by tachycardia, borderline hypotension, oliguria (less than 30 mL/hr), and a critically low hemoglobin level. The practical nurse must immediately escalate these findings to the registered nurse so that rapid medical interventions, such as intravenous fluid resuscitation or a blood transfusion, can be initiated.

Step-by-Step Solution

1
Analyze the client's vital signs and urine output.
The heart rate is elevated (112 beats/minute), blood pressure is borderline low (102/64 mm Hg), and urine output is critically low (20 mL/hr).
To identify early signs of impaired systemic perfusion.
2
Evaluate the laboratory results.
The hemoglobin is critically low at 7.6 g/dL (76 g/L).
To correlate the vital signs with a potential underlying cause, such as acute hemorrhage.
3
Synthesize the findings and determine the clinical priority.
The combination of findings strongly indicates hypovolemic shock, which is a life-threatening emergency that supersedes the client's pain.
To establish whether the situation requires immediate escalation over routine interventions.
4
Select the appropriate nursing action based on scope of practice.
Notify the registered nurse immediately.
Because the client is unstable and requires complex interventions (like fluid resuscitation or blood products) that are beyond the practical nurse's independent scope of practice.

Key Concept

Recognizing and Escalating Early Signs of Postoperative Hypovolemic Shock
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Topics

Reduction of Risk Potential

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