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Difficulty: EasyPhysiological Adaptation

A client is admitted to the medical unit with active gastrointestinal bleeding. Upon admission, the client's blood pressure was 122/80 mm Hg and heart rate was 78 beats per minute. One hour later, the practical nurse observes that the client's blood pressure has decreased to 98/62 mm Hg and the heart rate has increased to 112 beats per minute. Which action should the practical nurse take first?

  1. Notify the registered nurse immediately.Answer
  2. B
    Document the vital signs as expected findings.
  3. C
    Ask the client to rate their current level of abdominal pain.
  4. D
    Plan to reassess the vital signs in one hour.

Answer

Notify the registered nurse immediately.
The correct action is to notify the registered nurse immediately. The client's decreasing blood pressure and increasing heart rate, in the context of active bleeding, are classic early indicators of hypovolemic shock. This requires urgent escalation and intervention to restore circulatory volume.

Step-by-Step Solution

1
Analyze the client's current vital signs compared to their baseline.
The blood pressure has dropped and the heart rate has increased significantly.
Comparing current data to baseline helps identify trends in the client's physiological status.
2
Correlate the vital sign changes with the client's diagnosis.
The client has active gastrointestinal bleeding; the dropping blood pressure and rising heart rate suggest hypovolemic shock.
Recognizing the signs of circulatory compromise is a critical component of physiological adaptation.
3
Determine the highest priority action based on the PN scope of practice.
The most urgent action is to notify the RN or provider to initiate emergent treatment.
In acute emergencies, escalating care is necessary to protect the client's circulation (ABC prioritization).

Key Concept

Early recognition of hypovolemic shock
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Topics

Physiological Adaptation

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