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Difficulty: MediumPhysiological Adaptation

Upon entering the room of a client who underwent a bowel resection earlier in the shift, the practical nurse observes that the client is unusually restless and continuously picking at the bedsheets. The client's heart rate is 118 beats/min and blood pressure is 102/64 mm Hg, which represents a change from preoperative readings of 82 beats/min and 138/78 mm Hg. The client repeatedly states, 'I feel so thirsty.' Which action should the practical nurse take first?

  1. A
    Administer the prescribed as-needed pain medication for the restlessness.
  2. B
    Provide ice chips and apply a cool cloth to the client's forehead.
  3. Check the abdominal dressing and any surgical drains for excessive bleeding.Answer
  4. D
    Tell the client that feeling nervous and thirsty is expected after surgery.

Answer

The correct action is to check the abdominal dressing and any surgical drains for excessive bleeding.
The client is demonstrating early signs of hypovolemic shock, including an increased heart rate, borderline hypotension, restlessness, and severe thirst. In the postoperative period, these symptoms strongly suggest internal or external hemorrhage. The practical nurse must prioritize Circulation (ABCs) and immediately assess the surgical site and drains for bleeding to gather essential data for the registered nurse and healthcare provider.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client shows a significantly increased heart rate, decreased blood pressure, restlessness, and severe thirst compared to baseline.
Identifying acute changes from baseline is the first step in recognizing clinical deterioration.
2
Correlate the symptoms with potential postoperative complications.
The combination of tachycardia, borderline hypotension, altered mental status (restlessness), and thirst strongly indicates early hypovolemic shock.
Understanding the physiological meaning behind symptom clusters allows the nurse to anticipate the underlying problem.
3
Determine the priority nursing intervention.
The most appropriate action is to immediately inspect the surgical site for active bleeding before notifying the registered nurse.
Gathering focused data related to the suspected hemorrhage is essential for safe and effective collaborative care.

Key Concept

Recognition of Early Shock and Hemorrhage
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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