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Difficulty: MediumReduction of Risk Potential

A client is 6 hours post-operative following a total knee arthroplasty. During a routine assessment, the practical nurse notes that the client has produced only 15 mL of urine via the indwelling catheter over the past hour. The client's current vital signs are blood pressure 100/62 mm Hg, heart rate 108 bpm, and respirations 20 breaths/min. The client reports surgical site pain as 5 on a 0 to 10 scale. Which action should the practical nurse take first?

  1. Notify the registered nurse about the urine output and vital signs.Answer
  2. B
    Administer the prescribed as-needed analgesic for the surgical site pain.
  3. C
    Document the findings and reassess the urinary output in one hour.
  4. D
    Increase the continuous intravenous fluid infusion rate.

Answer

The priority action is to notify the registered nurse about the urine output and vital signs.
A urine output of less than 30 mL/hr combined with an increasing heart rate and low-normal blood pressure in a post-operative client strongly suggests fluid volume deficit or bleeding. The priority action is to immediately escalate these critical findings to the registered nurse or healthcare provider to reduce the risk of hypovolemic shock.

Step-by-Step Solution

1
Analyze the clinical data provided in the scenario.
The client has a urine output of 15 mL/hr (normal is greater than 30 mL/hr), an elevated heart rate of 108 bpm, and a low-normal blood pressure of 100/62 mm Hg.
Identifying abnormal clinical findings is the first step in risk reduction and early complication management.
2
Determine the potential complication based on the findings.
The combination of oliguria, tachycardia, and a dropping or borderline blood pressure in a post-operative client indicates a high risk for hypovolemia, hemorrhage, or impending shock.
Recognizing patterns of clinical deterioration guides proper prioritization.
3
Select the priority nursing action based on the practical nurse's scope of practice.
The most appropriate immediate action is to alert the registered nurse or healthcare provider.
The practical nurse must rapidly escalate signs of clinical instability to ensure the client receives prompt medical intervention.

Key Concept

Reduction of Risk Potential: Early Recognition of Post-Operative Complications
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Topics

Reduction of Risk Potential

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