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Difficulty: MediumReduction of Risk Potential

A client on a medical-surgical unit is recovering from a partial bowel resection performed 48 hours ago. The morning laboratory results reveal a hemoglobin level of 7.2 g/dL (72 g/L). The client's current vital signs show a heart rate of 114 beats/min, a respiratory rate of 22 breaths/min, and a blood pressure of 98/62 mm Hg. The client reports feeling lightheaded when sitting up in bed. Which action should the practical nurse take first?

  1. Report the assessment findings and laboratory results to the registered nurse immediately.Answer
  2. B
    Document the laboratory results as an expected finding associated with postoperative blood loss.
  3. C
    Provide a warm blanket and plan to reassess the vital signs in one hour.
  4. D
    Increase the rate of the continuous intravenous fluid infusion to treat the hypotension.

Answer

The correct action is to report the assessment findings and laboratory results to the registered nurse immediately.
The client is exhibiting clear signs of symptomatic anemia and potential hypovolemic shock, evidenced by tachycardia, hypotension, dizziness, and a significantly low hemoglobin level. The practical nurse must prioritize client safety by immediately escalating these critical findings to the registered nurse for urgent collaborative intervention, such as a blood transfusion or fluid resuscitation.

Step-by-Step Solution

1
Analyze the client's clinical data.
The client has a critically low hemoglobin level (7.2 g/dL), tachycardia (114 beats/min), hypotension (98/62 mm Hg), and symptoms of decreased perfusion (lightheadedness).
Identifying abnormal parameters is the first step in recognizing clinical deterioration.
2
Correlate the findings with potential postoperative complications.
These combined findings strongly suggest active internal bleeding, hypovolemia, or symptomatic anemia.
Connecting laboratory data with vital sign trends determines the severity of the client's risk.
3
Determine the priority nursing action within the practical nurse's scope of practice.
The priority is to immediately communicate these findings to the registered nurse or healthcare provider.
The client requires urgent interventions (e.g., blood transfusion, fluid resuscitation) that require collaborative management and exceed independent LPN/PN scope.

Key Concept

Reduction of Risk Potential: Recognizing and escalating early signs of hypovolemic shock
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Topics

Reduction of Risk Potential

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