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Difficulty: MediumReduction of Risk Potential

A practical nurse is assigned to care for a client who is 66 hours post-operative following a right total knee arthroplasty. The nurse observes that the client is becoming increasingly restless and reports feeling dizzy. The current vital signs are: heart rate 114114 beats/min, respiratory rate 2424 breaths/min, and blood pressure 100/64100/64 mm Hg (pre-operative baseline 136/82136/82 mm Hg). The morning hematocrit level is 26%26\%, a significant decrease from the pre-operative level of 39%39\%. Which of the following is the most appropriate action for the practical nurse to take?

  1. A
    Administer a prescribed intravenous push sedative to help manage the client's new onset of restlessness and confusion.
  2. B
    Reassess the vital signs in one hour, as mild tachycardia and decreased blood pressure are expected effects of anesthesia.
  3. Immediately report the changes in vital signs and the decreased hematocrit level to the registered nurse.Answer
  4. D
    Document the hematocrit level in the medical record, noting that this decrease is a standard outcome following joint replacement.

Answer

The practical nurse should immediately escalate the findings to the registered nurse due to the clear indicators of hypovolemic shock.
The client is exhibiting restlessness, tachycardia, hypotension, and a significantly decreased hematocrit level, which are classic signs of internal bleeding and early hypovolemic shock following major orthopedic surgery. Recognizing these life-threatening complications and immediately escalating the findings to the registered nurse is the highest priority. This ensures the client will receive timely, advanced interventions such as aggressive fluid resuscitation or a blood transfusion.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client shows restlessness, dizziness, tachycardia (114114 beats/min), and hypotension (100/64100/64 mm Hg from a baseline of 136/82136/82 mm Hg).
These are classic early indicators of poor tissue perfusion and compensatory mechanisms for blood loss.
2
Evaluate the laboratory results against expected post-operative ranges.
The hematocrit has dropped significantly from 39%39\% to 26%26\%.
While some blood loss is expected after major joint arthroplasty, a 13%13\% drop in hematocrit is critical and indicates severe hemorrhage.
3
Determine the appropriate nursing intervention within the practical nurse scope of practice.
The immediate priority is to notify the registered nurse and the healthcare provider.
The client is experiencing a life-threatening complication that requires advanced assessment, fluid resuscitation, or a potential blood transfusion, which necessitates registered nurse and provider collaboration.

Key Concept

Early Recognition of Shock and Scope of Practice
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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