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Difficulty: MediumReduction of Risk Potential

A practical nurse is providing care for a client who is four hours postoperative following a total abdominal hysterectomy. The client reports incisional pain rated as a 4 on a 0 to 10 scale and mild nausea. Current vital signs reveal a temperature of 99.1°F (37.3°C), a heart rate of 116 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 92/56 mm Hg. The client's preoperative blood pressure was 122/76 mm Hg. Which action should the nurse take first?

  1. Alert the charge nurse about the current vital signs immediatelyAnswer
  2. B
    Record the assessment data and plan to recheck the measurements in one hour
  3. C
    Provide the prescribed as-needed antiemetic to address the client's mild nausea
  4. D
    Independently increase the maintenance intravenous fluid rate to raise the blood pressure

Answer

Alert the charge nurse about the current vital signs immediately.
The correct action is to immediately notify the supervising nurse. The client's tachycardia (116 beats/minute) and drop in blood pressure from the baseline are early clinical indicators of hypovolemic shock, likely due to postoperative hemorrhage. The practical nurse must recognize this critical change and rapidly escalate the findings to ensure immediate intervention.

Step-by-Step Solution

1
Analyze the client's postoperative vital signs against baseline parameters.
The heart rate is elevated at 116 beats/minute, and the blood pressure has decreased significantly from 122/76 mm Hg to 92/56 mm Hg.
Identifying trends in vital signs is essential for recognizing early complications.
2
Determine the clinical significance of these findings.
Tachycardia combined with hypotension in a postoperative client strongly suggests hypovolemia or internal hemorrhage.
Changes in circulating blood volume trigger compensatory mechanisms, such as an increased heart rate, before cardiovascular collapse occurs.
3
Select the appropriate nursing intervention based on scope of practice.
The practical nurse must immediately report these critical findings to the charge nurse or registered nurse for further assessment and intervention.
Escalating deteriorating client conditions ensures timely medical management and reduces the potential for risk or severe injury.

Key Concept

Recognizing and Escalating Early Signs of Postoperative Shock
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Topics

Reduction of Risk Potential

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