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Difficulty: HardReduction of Risk Potential

A practical nurse is conducting a postoperative assessment on a 7272-year-old client who underwent a transurethral resection of the prostate (TURP) three hours ago. The client is receiving continuous bladder irrigation (CBI). Which clinical finding requires the most immediate escalation to the supervising registered nurse?

  1. A gradual increase in the client's resting heart rate from 7676 to 114114 beats per minute over the past hour.Answer
  2. B
    A postoperative serum sodium level reported as 138138 mEq/L (138138 mmol/L).
  3. C
    The bedside barcode scanner malfunctions while the nurse is preparing to administer a scheduled oral multivitamin.
  4. D
    An unlicensed assistive personnel (UAP) is observed emptying the urinary drainage bag and recording the output volume.

Answer

The correct answer is the gradual increase in the resting heart rate from 7676 to 114114 beats per minute, which is an early indicator of hypovolemic shock or severe hemorrhage.
A steadily increasing heart rate in a postoperative client is a classic early, compensatory sign of hypovolemia and potential hemorrhage. Because the client recently underwent a highly vascular prostate resection, this subtle cardiovascular change requires immediate escalation to the registered nurse for prompt intervention and evaluation of bleeding.

Step-by-Step Solution

1
Analyze the client's postoperative timeframe and current therapy.
The client is three hours post-TURP receiving continuous bladder irrigation, making them at high risk for hemorrhage and fluid shifts.
Identifying the procedure context helps anticipate potential life-threatening complications.
2
Evaluate the vital sign trend.
A heart rate increase from 7676 to 114114 beats per minute is a significant physiological change.
Tachycardia is often the first subtle, compensatory sign of hypovolemia and hemorrhage before the blood pressure drops.
3
Review the remaining clinical findings for priority.
The serum sodium is normal, the medication technical issue is low acuity, and the UAP's action is within their scope of practice.
Using the ABC (Airway, Breathing, Circulation) framework confirms that the cardiovascular change is the highest priority requiring immediate escalation.

Key Concept

Postoperative Complication Recognition and Prioritization
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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