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Difficulty: EasyPhysiological Adaptation

While assisting a postoperative client who underwent abdominal surgery earlier in the day, a practical nurse obtains the following vital signs: temperature 98.8°F (37.1°C), heart rate 116 beats/min, respiratory rate 20 breaths/min, and blood pressure 92/54 mm Hg. The client's admission baseline blood pressure was 128/74 mm Hg. Which action should the nurse prioritize?

  1. A
    Plan to recheck the blood pressure and pulse in one hour.
  2. B
    Elevate the head of the bed to a high-Fowler's position.
  3. Report the assessment data to the supervising registered nurse.Answer
  4. D
    Evaluate the surgical incision site for current pain intensity.

Answer

The priority is to report the assessment data to the supervising registered nurse to address the potential circulatory compromise.
The correct action is communicating the abnormal vital signs to the supervising registered nurse. Tachycardia combined with a significant drop in blood pressure are classic early signs of shock or internal hemorrhage. Identifying and reporting circulatory instability addresses the 'C' (Circulation) in the ABC prioritization framework and is the most critical safety action.

Step-by-Step Solution

1
Analyze the obtained vital signs against the baseline data.
The heart rate is elevated (116 beats/min) and the blood pressure has dropped significantly (92/54 mm Hg) compared to the baseline (128/74 mm Hg).
Comparing current data to baseline helps identify acute physiological changes.
2
Identify the clinical significance of these vital sign changes.
Tachycardia and hypotension in a postoperative client are classic early indicators of decreased cardiac output, hypovolemia, or internal hemorrhage.
Recognizing signs of shock is essential for preventing rapid deterioration.
3
Determine the priority intervention within the practical nursing scope of practice.
The supervising RN must be informed immediately to facilitate rapid assessment and medical intervention.
The practical nurse must escalate care when unstable or critical physiological changes are detected.

Key Concept

Early recognition of hypovolemic shock and timely escalation of care
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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