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Difficulty: HardPharmacological Therapies

A practical nurse (PN) is collecting data on a client who is 24 hours postoperative following an abdominal hysterectomy. The client reports an incisional pain level of 8 on a 0 to 10 scale and requests their prescribed as-needed (PRN) oral hydrocodone-acetaminophen. The PN notes the client is restless with pale, cool skin. The client's vital signs are: blood pressure 92/54 mm Hg, apical pulse 118 beats/minute, and respirations 22 breaths/minute. Which of the following actions should the PN take first?

  1. A
    Administer the prescribed hydrocodone-acetaminophen promptly to alleviate the client's severe pain.
  2. B
    Document the vital signs and reassess the client in 30 minutes before administering the medication.
  3. C
    Increase the rate of the client's continuous intravenous fluids to treat the low blood pressure.
  4. Withhold the hydrocodone-acetaminophen and immediately notify the registered nurse.Answer

Answer

The practical nurse should withhold the hydrocodone-acetaminophen and immediately notify the registered nurse.
The client's clinical presentation (tachycardia, hypotension, restlessness, pale and cool skin) strongly suggests hypovolemic shock, a serious postoperative complication. Opioid analgesics like hydrocodone can cause vasodilation and further lower blood pressure. Therefore, administering the medication is unsafe. The practical nurse is acting correctly within their scope of practice by withholding the contraindicated medication and immediately reporting the critical change in condition to the registered nurse for advanced assessment and intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client has a low blood pressure (92/54 mm Hg), elevated heart rate (118 beats/minute), elevated respiratory rate (22 breaths/minute), restlessness, and pale, cool skin.
Data collection is the first step in the nursing process to determine the client's current physiological status.
2
Interpret the clinical findings in the context of the postoperative period.
These findings are early signs of hypovolemia or hemorrhage, which is a life-threatening complication of an abdominal hysterectomy.
Recognizing signs of shock is critical for prioritizing care based on the Airway, Breathing, Circulation (ABC) framework.
3
Evaluate the safety of administering the prescribed medication.
Hydrocodone-acetaminophen is an opioid, which can cause vasodilation and further decrease blood pressure, making it contraindicated in this unstable state.
The nurse must ensure pharmacological therapies are safe to administer based on current client data.
4
Determine the appropriate action within the practical nurse scope of practice.
The nurse must withhold the unsafe medication and immediately communicate the critical findings to the registered nurse.
Practical nurses are responsible for withholding medications that pose a risk and reporting abnormal findings to the directing RN or provider.

Key Concept

Recognizing signs of hypovolemic shock and appropriately withholding contraindicated medications while escalating care within the practical nursing scope of practice.
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Topics

Pharmacological Therapies

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