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Difficulty: HardPhysiological Adaptation

A 68-year-old client is 12 hours postoperative following a partial nephrectomy. The client uses the call light to report incisional pain rated 8 on a 0 to 10 scale. Upon entering the room, the practical nurse (PN) notes the client is restless, slightly diaphoretic, and confused about the current day of the week. Vital signs are temperature 98.4°F (36.9°C), pulse 116 bpm, respiratory rate 22/min, and blood pressure 106/62 mm Hg. The client's preoperative blood pressure was 142/84 mm Hg. Which action should the PN take FIRST?

  1. Inspect the surgical dressing and dependent areas for bleeding, then immediately notify the registered nurse.Answer
  2. B
    Administer the prescribed as-needed analgesic to address the client's severe postoperative pain.
  3. C
    Document the current vital signs in the electronic health record and reassess the client in 30 minutes.
  4. D
    Reorient the client to the current day and explain that confusion is common after receiving general anesthesia.

Answer

The correct action is to inspect the surgical dressing and dependent areas for bleeding, then immediately notify the registered nurse.
The correct answer directly addresses the most immediate threat to the client's life. Restlessness, new-onset confusion, tachycardia, and a significant drop in blood pressure from baseline are early compensatory signs of hypovolemic shock, likely due to postoperative hemorrhage. The practical nurse must quickly assess for visible bleeding (dressing, drains, or pooling underneath the client) and immediately escalate the findings to the registered nurse for rapid intervention.

Step-by-Step Solution

1
Analyze the client's symptoms and vital sign trends compared to the baseline.
The client has tachycardia, a significant drop in blood pressure from baseline, restlessness, and new-onset confusion.
Identifying deviations from baseline helps differentiate normal postoperative recovery from acute complications.
2
Synthesize the findings to identify the underlying physiological problem.
The combination of narrowed pulse pressure, tachycardia, diaphoresis, and altered mental status indicates inadequate systemic perfusion.
These are classic early compensatory signs of hypovolemic shock, highly likely resulting from internal hemorrhage following a vascular surgery like a nephrectomy.
3
Apply the Airway, Breathing, Circulation (ABC) prioritization framework to determine the immediate nursing action within the PN scope of practice.
Circulation takes priority over pain management or routine documentation. The PN must gather focused data on the source of bleeding and escalate the situation.
Rapid identification and reporting of hemorrhage are required for emergency intervention to prevent severe hypovolemic shock and cardiovascular collapse.

Key Concept

Early Recognition of Hypovolemic Shock and Prioritization
Estimated Time:1m 15s
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Topics

Physiological Adaptation

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