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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is collecting data on a client admitted with a severe exacerbation of ulcerative colitis. The client has had several large, bloody bowel movements over the past four hours. The client's current vital signs are: heart rate 112 beats/min, blood pressure 106/68 mm Hg, and respiratory rate 22 breaths/min. The client's admission vital signs were: heart rate 78 beats/min, blood pressure 134/82 mm Hg, and respiratory rate 16 breaths/min. The client appears restless and reports abdominal cramping. Which action should the PN take first?

  1. Notify the registered nurse (RN) about the changes in the client's condition.Answer
  2. B
    Document the vital signs and re-evaluate the client in one hour.
  3. C
    Administer the prescribed PRN oral analgesic for the abdominal cramping.
  4. D
    Assist the client in using relaxation techniques to decrease restlessness.

Answer

The correct action is to notify the registered nurse (RN) about the changes in the client's condition.
The client is exhibiting early, compensatory signs of hypovolemic shock due to significant blood and fluid loss from the ulcerative colitis exacerbation. The increased heart rate, dropping blood pressure, and new-onset restlessness (indicating decreased cerebral perfusion) require immediate medical intervention. Within the practical nurse (PN) scope of practice, recognizing acute decompensation and immediately notifying the registered nurse (RN) is the highest priority action to ensure life-saving treatments are initiated promptly.

Step-by-Step Solution

1
Analyze the client's current vital signs and compare them to the admission baseline.
The heart rate has increased significantly (from 78 to 112 beats/min), blood pressure has dropped (from 134/82 to 106/68 mm Hg), and the client is restless.
Identifying trends in vital signs is crucial for detecting physiological decompensation early.
2
Correlate the assessment findings with the client's clinical presentation.
The history of large, bloody bowel movements combined with tachycardia, relative hypotension, and restlessness indicates acute fluid volume deficit and impending hypovolemic shock.
Understanding the cause of the vital sign changes guides appropriate prioritization and intervention.
3
Determine the highest priority nursing action based on the Airway, Breathing, and Circulation (ABC) framework and the PN scope of practice.
The priority is to address the circulatory compromise by immediately notifying the RN, who can initiate intravenous fluid resuscitation and contact the healthcare provider.
Escalating a critical change in condition ensures the client receives timely, life-saving interventions.

Key Concept

Early recognition of hypovolemic shock and prompt escalation of care.
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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