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Difficulty: HardReduction of Risk Potential

A client is recovering on the surgical unit following a vaginal hysterectomy performed earlier in the day. During an afternoon assessment, the practical nurse (PN) notes that the client's heart rate has climbed from a baseline of 78 bpm to 112 bpm, while the blood pressure has decreased from 126/82 mm Hg to 102/60 mm Hg. A stat hemoglobin result from the laboratory is 7.4 g/dL (74 g/L). Which of the following actions should the PN take? Select all that apply.

  1. Examine the perineal pads and the linens beneath the client for evidence of excessive bleeding.Answer
  2. Immediately communicate the changing physiological parameters and laboratory values to the registered nurse (RN).Answer
  3. Confirm the patency of the client's existing peripheral intravenous (IV) catheter.Answer
  4. D
    Assume the hemoglobin value is an expected post-surgical finding and wait for the morning labs before notifying the registered nurse (RN).
  5. E
    Document the vital signs as a normal physiological response to surgical pain and plan to reassess in two hours.
  6. F
    Elevate the head of the bed to a high-Fowler's position to promote client comfort and optimal lung expansion.

Answer

The correct actions include examining the perineal pads and linens for bleeding, communicating the findings to the RN immediately, and confirming the patency of the client's peripheral IV catheter.
The client's increasing heart rate, decreasing blood pressure, and low hemoglobin of 7.4 g/dL (74 g/L) are classic signs of hypovolemic shock, likely due to post-operative hemorrhage. The appropriate nursing actions within the practical nurse scope involve immediately assessing for the source of the bleeding (perineal pads and linens), urgently escalating the critical findings to the registered nurse for provider notification, and ensuring that peripheral IV access is patent in anticipation of fluid or blood administration.

Step-by-Step Solution

1
Analyze the client's clinical data and identify trends.
The client has an increasing heart rate (78 to 112 bpm), a decreasing blood pressure (126/82 to 102/60 mm Hg), and a critically low hemoglobin of 7.4 g/dL.
Identifying changes from baseline is essential to detect acute post-operative complications.
2
Recognize the underlying clinical complication.
The combination of tachycardia, hypotension, and anemia in a post-surgical client strongly indicates hypovolemic shock secondary to hemorrhage.
Tachycardia is often the earliest compensatory sign of shock, followed by a drop in blood pressure.
3
Determine the appropriate PN interventions to mitigate risk.
The PN must assess for the source of bleeding, escalate the critical findings to the RN, and prepare for potential resuscitation by checking IV access.
These actions fall safely within the PN scope of practice and directly address the life-threatening risk without overstepping into independent medical intervention.

Key Concept

Post-Operative Hemorrhage and Hypovolemic Shock Recognition
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Topics

Reduction of Risk Potential

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