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Difficulty: MediumReduction of Risk Potential

A practical nurse is collecting data from a client who is 2 hours postoperative following an abdominal hysterectomy. The client's vital signs are: blood pressure 98/60 mm Hg, heart rate 114 beats per minute, respiratory rate 18 breaths per minute, and oxygen saturation 96% on room air. The client reports incisional pain as 6 on a 0 to 10 pain scale. Which action should the practical nurse take first?

  1. Notify the registered nurse about the vital signs immediatelyAnswer
  2. B
    Document the findings as an expected physiological response to surgical stress
  3. C
    Administer an intravenous push opioid analgesic to manage the incisional pain
  4. D
    Provide the prescribed oral pain medication and reassess the pain level in 30 minutes

Answer

Notify the registered nurse about the vital signs immediately
The correct action is to notify the registered nurse immediately because a heart rate of 114 beats per minute and a blood pressure of 98/60 mm Hg are early indicators of hypovolemic shock and potential internal hemorrhage following major surgery. Rapid escalation is essential for client safety.

Step-by-Step Solution

1
Analyze the client's vital signs against expected postoperative baselines.
The heart rate of 114 beats per minute and blood pressure of 98/60 mm Hg are abnormal.
Identifying deviations from normal values is required to recognize early complications.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The vital signs indicate a potential issue with circulation (hypovolemia or hemorrhage).
Circulatory compromise is life-threatening and takes priority over managing the client's pain.
3
Determine the appropriate scope of practice for the practical nurse in this scenario.
The practical nurse must immediately report these critical findings to the registered nurse for further assessment and intervention.
Practical nurses must escalate sudden signs of instability to the RN or provider for advanced clinical judgment.

Key Concept

Early recognition of hypovolemic shock and appropriate escalation.
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Topics

Reduction of Risk Potential

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