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Difficulty: MediumReduction of Risk Potential

A licensed practical nurse is caring for an adult client who underwent an open reduction and internal fixation of a right femur fracture 8 hours ago. During the current assessment, the nurse notes a heart rate of 118 beats/minute, a blood pressure of 96/62 mm Hg, and a respiratory rate of 22 breaths/minute. Additionally, the surgical dressing exhibits a newly formed, 4-cm diameter area of sanguineous drainage. What is the priority action for the nurse to take?

  1. A
    Trace the outline of the drainage on the dressing and reassess the client in one hour.
  2. B
    Administer the prescribed as-needed oral opioid analgesic for postoperative pain.
  3. C
    Increase the continuous intravenous fluid infusion rate to stabilize the blood pressure.
  4. Immediately report the assessment findings to the supervising registered nurse.Answer

Answer

Immediately report the assessment findings to the supervising registered nurse.
The client is demonstrating early signs of hypovolemic shock, likely due to postoperative hemorrhage, evidenced by tachycardia, borderline hypotension, and new sanguineous drainage. In the practical nursing scope of practice, recognizing an acute deterioration in client stability requires immediate escalation to the registered nurse or healthcare provider so that emergent interventions (such as fluid resuscitation or surgical evaluation) can be initiated.

Step-by-Step Solution

1
Analyze the client's vital signs and physical assessment findings.
The client has tachycardia (118 beats/minute), borderline hypotension (96/62 mm Hg), and new sanguineous drainage on the surgical dressing.
Identifying abnormal clinical data is the first step in recognizing potential complications.
2
Correlate the findings with potential postoperative complications.
The combination of elevated heart rate, decreasing blood pressure, and fresh bleeding indicates a high risk for hypovolemic shock due to hemorrhage.
Connecting isolated vital sign changes to underlying physiological processes determines the urgency of the situation.
3
Determine the appropriate action based on the practical nurse's scope of practice.
The nurse must escalate the findings to the registered nurse or healthcare provider immediately rather than attempting independent, out-of-scope interventions or delaying care.
Practical nursing standards require reporting acute changes in a client's condition that indicate instability to the supervising RN or provider.

Key Concept

Recognition and escalation of early shock indicators in postoperative clients
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Topics

Reduction of Risk Potential

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