During morning rounds, a practical nurse (PN) evaluates a client who had an open appendectomy 6 hours earlier. The baseline vital signs recorded upon transfer from the post-anesthesia care unit were a blood pressure of 122/78 mm Hg and a heart rate of 76 beats/min. The current vital signs show a blood pressure of 100/64 mm Hg and a heart rate of 108 beats/min. The client complains of feeling slightly dizzy. Which action should the PN take first?
- Report the assessment findings to the supervising registered nurse (RN).Answer
- BProvide the prescribed PRN pain medication for postoperative discomfort.
- CRecord the vital signs in the electronic health record and recheck in one hour.
- DElevate the head of the client's bed to a high Fowler's position.
Answer
Report the assessment findings to the supervising registered nurse (RN).
The client is exhibiting early signs of compensatory shock, likely due to postoperative hemorrhage or hypovolemia. The combination of a decreasing blood pressure, an increasing heart rate, and dizziness requires immediate escalation to the RN or provider for further assessment and intervention to prevent clinical deterioration.
Step-by-Step Solution
Key Concept
Early Recognition of Postoperative Hypovolemia