Examkin

Question

Difficulty: MediumReduction of Risk Potential

An individual is recovering on the surgical unit twelve hours after an open cholecystectomy. The morning laboratory report indicates a hemoglobin of 8.2 g/dL (82 g/L). The practical nurse obtains the client's current vital signs, noting a heart rate of 114 beats per minute and a blood pressure of 98/60 mm Hg. Based on these findings, which action is the priority for the practical nurse?

  1. Promptly notify the supervising registered nurse about the client's vital signs and the recent laboratory valuesAnswer
  2. B
    Document the data in the electronic health record, recognizing that a moderate decrease in hemoglobin is typical after abdominal surgery
  3. C
    Wait to reassess the heart rate and blood pressure in one hour, as mild tachycardia can commonly result from post-operative pain
  4. D
    Obtain the prescribed unit of packed red blood cells from the blood bank and independently initiate the transfusion

Answer

Promptly notify the supervising registered nurse about the client's vital signs and the recent laboratory values.
The client is exhibiting classic signs of hemorrhagic shock, specifically tachycardia and hypotension, combined with a significantly low hemoglobin level. The practical nurse must immediately escalate these life-threatening findings to the registered nurse for prompt intervention, as the client's condition is unstable and requires care beyond the practical nurse scope.

Step-by-Step Solution

1
Analyze the client's vital signs.
The heart rate of 114 beats per minute (tachycardia) and blood pressure of 98/60 mm Hg (hypotension) are identified as abnormal.
Recognizing deviations from normal vital sign ranges is the first step in identifying postoperative complications.
2
Evaluate the morning laboratory results in conjunction with the physical assessment data.
The significantly low hemoglobin of 8.2 g/dL aligns with the unstable vital signs.
Correlating laboratory data with clinical signs helps pinpoint the specific complication, which in this case points to acute blood loss.
3
Synthesize the findings to determine the immediate clinical risk.
The combination of tachycardia, hypotension, and low hemoglobin indicates a high risk for internal postoperative hemorrhage and hypovolemic shock.
Identifying the complication dictates the urgency of the required intervention.
4
Determine the appropriate action based on the practical nurse's scope of practice.
The nurse must immediately escalate the situation to the registered nurse or healthcare provider.
Unstable clients requiring complex assessment, fluid resuscitation, and blood product administration must be managed by the registered nurse and provider.

Key Concept

Reduction of Risk Potential: Recognizing and escalating signs of postoperative hemorrhage
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic