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Difficulty: HardReduction of Risk Potential

A practical nurse is caring for a client who returned to the medical-surgical unit 2 hours ago following a colonoscopy with multiple polyp removals. The client reports feeling "a bit lightheaded" and excessively thirsty. The client's current vital signs are: blood pressure 102/64 mm Hg, apical heart rate 114 beats/minute, and respiratory rate 20 breaths/minute. The client's pre-procedure baseline vital signs were blood pressure 136/84 mm Hg and heart rate 72 beats/minute. Which action should the nurse take first?

  1. Lower the head of the client's bed and immediately notify the registered nurse.Answer
  2. B
    Provide a small amount of oral fluids for the thirst and reassess vital signs in 30 minutes.
  3. C
    Instruct the client to take slow, deep breaths to help alleviate the lightheadedness.
  4. D
    Independently increase the rate of the client's continuous intravenous fluid infusion.

Answer

The correct action is to lower the head of the client's bed and immediately notify the registered nurse.
The correct answer addresses both the immediate physical need (lowering the head of the bed to promote venous return and cerebral blood flow) and the professional requirement (notifying the RN of a critical change). A colonoscopy with polyp removal creates a risk for intestinal perforation or hemorrhage. The combination of tachycardia, relative hypotension, extreme thirst, and lightheadedness points directly to internal bleeding and early hypovolemic shock, requiring immediate medical escalation.

Step-by-Step Solution

1
Analyze the client's current vital signs by comparing them to the pre-procedure baseline.
The heart rate has increased significantly (from 72 to 114) and the blood pressure has dropped substantially (from 136/84 to 102/64).
Comparing current data to baseline is essential to identify physiological deterioration rather than just relying on standard normal ranges.
2
Correlate the clinical findings (tachycardia, hypotension, thirst, lightheadedness) with the recent procedure.
The findings indicate decreased intravascular volume. Polyp removal involves cutting tissue, which carries a high risk for internal hemorrhage.
Understanding procedural risks helps pinpoint the cause of the vital sign changes as a potential hemorrhagic complication.
3
Determine the priority nursing intervention based on the practical nurse scope of practice.
The client requires immediate repositioning to maintain brain perfusion and prompt escalation to the RN for medical intervention.
The PN must initiate basic life-saving positioning (lowering the head of the bed) and immediately involve the RN, as independently changing IV rates or delaying care is unsafe.

Key Concept

Early Recognition and Escalation of Hypovolemic Shock Post-Procedure
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Topics

Reduction of Risk Potential

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