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Difficulty: EasyReduction of Risk Potential

A practical nurse is assessing a client who is recovering from a total knee arthroplasty performed earlier in the day. Over the past few hours, the client's heart rate has steadily increased from 82 to 118 beats per minute, and their blood pressure has dropped from 124/76 mm Hg to 94/56 mm Hg. The client states, "I just feel really tired." Which of the following is the most appropriate immediate action for the nurse to take?

  1. Report the vital sign changes to the registered nurse or healthcare provider.Answer
  2. B
    Document the vital signs in the medical record and recheck them in two hours.
  3. C
    Administer a prescribed oral analgesic to help the client rest comfortably.
  4. D
    Increase the continuous intravenous fluid rate to improve the client's blood pressure.

Answer

Report the vital sign changes to the registered nurse or healthcare provider.
The correct action is to immediately notify the registered nurse or healthcare provider. A rising heart rate combined with a falling blood pressure in a postoperative client strongly suggests internal bleeding or hypovolemic shock. Because practical nurses work under the direction of an RN or provider, escalating critical changes in condition is the essential next step to reduce the risk of a severe complication.

Step-by-Step Solution

1
Analyze the client's vital sign trends and current symptoms.
The heart rate has increased significantly while the blood pressure has decreased.
Identifying these specific trends helps recognize the early physiological signs of hypovolemia or shock.
2
Determine the priority intervention based on the practical nurse's scope of practice.
The nurse must escalate the findings to a higher level of care provider.
Signs of impending shock require immediate medical evaluation and interventions that may exceed the independent scope of a practical nurse.

Key Concept

Recognition and Escalation of Early Shock
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Topics

Reduction of Risk Potential

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