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Difficulty: EasyReduction of Risk Potential

A client is receiving care on a medical unit for fluid volume deficit caused by severe gastroenteritis. During afternoon rounds, the practical nurse notes that the client has voided a total of 55 mL55\text{ mL} of concentrated urine over the past three hours. The client's current heart rate is 104104 beats per minute and blood pressure is 102/68 mm Hg102/68\text{ mm Hg}, compared to a baseline of 122/78 mm Hg122/78\text{ mm Hg}. Which action should the nurse prioritize?

  1. Alert the assigned registered nurse to the current clinical findings.Answer
  2. B
    Document the urine volume and plan to recheck the vital signs in two hours.
  3. C
    Offer the client a cup of oral rehydration fluid to stimulate kidney function.
  4. D
    Instruct the unlicensed assistive personnel to ambulate the client to the bathroom.

Answer

The priority action is to immediately notify the registered nurse of the client's borderline vital signs and decreased urine output.
The correct answer emphasizes the practical nurse's responsibility to recognize early signs of a deteriorating condition and escalate them without delay. A urine output of less than 30 mL30\text{ mL} per hour combined with mild tachycardia and a dropping blood pressure are early indicators of hypovolemic shock. The registered nurse must be alerted to perform a comprehensive assessment and coordinate with the healthcare provider for potential intravenous fluid resuscitation.

Step-by-Step Solution

1
Analyze the urine output data.
The client produced 55 mL over 3 hours, which averages to about 18 mL per hour.
Normal minimum urine output is 30 mL per hour; an output of 18 mL per hour indicates oliguria, a sign of poor renal perfusion.
2
Evaluate the vital sign trends.
The heart rate is elevated at 104 beats per minute and blood pressure has decreased significantly from the baseline.
Tachycardia and hypotension are early compensatory mechanisms for decreased circulating blood volume.
3
Determine the required nursing action.
The practical nurse must escalate these findings to the registered nurse immediately.
It is within the practical nurse's scope of practice to recognize life-threatening trends, such as hypovolemic shock, and promptly initiate the escalation process for further medical intervention.

Key Concept

Early Recognition and Escalation of Hypovolemic Shock
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Topics

Reduction of Risk Potential

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