Examkin

Question

Difficulty: MediumPhysiological Adaptation

An older adult client is receiving continuous intravenous heparin for a deep vein thrombosis. During hourly rounds, the client reports sudden, severe lower back pain and mild dizziness. The client appears restless and the skin is cool to the touch. Which action should the practical nurse take first?

  1. Measure the client's current blood pressure and heart rate.Answer
  2. B
    Administer the client's prescribed as-needed analgesic for pain.
  3. C
    Reorient the client to the hospital environment and provide reassurance.
  4. D
    Document the client's symptoms and continue routine monitoring.

Answer

Measure the client's current blood pressure and heart rate.
The correct action is to measure the blood pressure and heart rate. A client on continuous heparin experiencing sudden back pain accompanied by dizziness, restlessness, and cool skin is exhibiting classic signs of a retroperitoneal hemorrhage and early hypovolemic shock. Assessing circulatory status by collecting vital signs is the immediate priority for the practical nurse to confirm the complication and promptly report the findings to the registered nurse.

Step-by-Step Solution

1
Analyze the client's new symptoms in the context of their current therapy.
The client is on heparin (high bleeding risk). Sudden back pain, dizziness, restlessness, and cool skin are indicative of a retroperitoneal hemorrhage and early hypovolemic shock.
To identify potential life-threatening complications requiring immediate intervention.
2
Apply the ABC (Airway, Breathing, Circulation) priority framework to the clinical picture.
The symptoms point to a critical circulation issue, which takes precedence over comfort measures or routine documentation.
Airway, breathing, and circulation are always the highest priorities in acute care.
3
Determine the appropriate initial action within the practical nursing scope of practice.
Obtaining a current set of vital signs provides objective data about the client's hemodynamic status.
Current vital signs are necessary to confirm circulatory compromise and properly escalate the situation to the registered nurse or healthcare provider.

Key Concept

Prioritization of care and early recognition of hypovolemic shock in clients receiving anticoagulants.
Rate this question

Topics

Physiological Adaptation

More questions from this topic