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Difficulty: MediumData Collection Techniques

A practical nurse (PN) is evaluating a 42-year-old client who had an open bowel resection 4 hours ago. The client reports feeling unusually thirsty and restless. The PN measures the vital signs and notes a heart rate of 115 beats/min and a blood pressure of 96/60 mm Hg. The client's admission blood pressure was 128/82 mm Hg. What is the most appropriate next step for the PN regarding data collection and reporting?

  1. Inspect the abdominal surgical dressing and the bed linens underneath the client for signs of bleeding, then immediately notify the registered nurse.Answer
  2. B
    Document the vital signs as stable, assuming the slight changes are an expected reaction to waking up from general anesthesia.
  3. C
    Prioritize assessing the client's pain level using a numeric rating scale and administer the prescribed as-needed pain medication.
  4. D
    Independently increase the rate of the client's intravenous fluid infusion to improve circulation before gathering more data.

Answer

The most appropriate action is to inspect the surgical dressing and linens for bleeding and then notify the registered nurse.
The correct action demonstrates an understanding of the practical nurse's role in focused data collection and prioritized care. The client's symptoms (tachycardia, mild hypotension, restlessness, and thirst) are early signs of hypovolemic shock, which is a life-threatening complication of surgery. The PN correctly identifies the need for focused data collection by checking the dressing for hemorrhage and initiating immediate escalation to the registered nurse.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a significantly increased heart rate, decreased blood pressure, restlessness, and thirst 4 hours postoperatively.
Identifying abnormal data is the first step in clinical decision-making.
2
Correlate the findings with potential postoperative complications.
These findings are classic early signs of hypovolemic shock, likely due to hemorrhage.
Connecting signs and symptoms to potential physiological problems ensures prioritized care.
3
Determine the appropriate focused data collection within the PN scope of practice.
The PN must quickly look for the source of potential fluid loss by inspecting the surgical site and surrounding area.
Focused physical data collection helps confirm the suspicion before reporting to the RN.
4
Identify the required communication step.
The PN must immediately report the abnormal vital signs and physical findings to the registered nurse.
Changes in client condition indicating potential shock require prompt RN and provider intervention.

Key Concept

Recognizing early signs of shock and performing focused data collection
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Topics

Data Collection Techniques

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