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Difficulty: HardReduction of Risk Potential

While conducting a postoperative assessment, a practical nurse evaluates a client who returned to the surgical unit four hours ago following a vaginal hysterectomy. The client reports feeling unusually thirsty and mildly dizzy. The nurse notes moderate bright red drainage on the perineal pad. The client's current vital signs show a blood pressure of 106/74 mm Hg (baseline 132/84 mm Hg) and a heart rate of 98 beats/minute. Which of the following is the priority action for the practical nurse?

  1. Place the client in a supine position and immediately alert the registered nurse.Answer
  2. B
    Record the vital signs and drainage amount in the chart as expected early postoperative findings.
  3. C
    Provide the client with a small amount of oral fluids to relieve the thirst and plan to reassess in one hour.
  4. D
    Increase the rate of the continuous intravenous fluid infusion to help stabilize the blood pressure.

Answer

The correct action is to place the client in a supine position and immediately alert the registered nurse.
The correct answer directly addresses the client's circulatory compromise by placing them in a supine position to promote venous return to the vital organs, while appropriately escalating the situation to the registered nurse. The client's thirst, dizziness, dropping blood pressure relative to baseline, and borderline tachycardia are classic early indicators of hypovolemic shock due to hemorrhage.

Step-by-Step Solution

1
Analyze the client's symptoms and vital sign trends.
The client is exhibiting early signs of hypovolemic shock, including a significant drop in blood pressure from baseline, borderline tachycardia, dizziness, and thirst.
Recognizing subtle changes is crucial for preventing severe circulatory complications before frank hypotension occurs.
2
Identify the practical nurse's scope of practice in an emergent situation.
The nurse must escalate these critical findings to the registered nurse or provider immediately.
Practical nurses cannot independently order or initiate fluid resuscitation or disregard signs of impending shock.
3
Determine the safest immediate bedside action.
Placing the client supine promotes venous return to vital organs while help is summoned.
Airway, breathing, and circulation (ABC) prioritization dictates immediate, non-invasive intervention to support circulatory status while waiting for advanced directives.

Key Concept

Early Recognition of Hypovolemic Shock and LPN Scope of Practice
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Topics

Reduction of Risk Potential

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