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Difficulty: EasyReduction of Risk Potential

A client is resting in bed 6 hours after an open cholecystectomy. While measuring vital signs, the practical nurse notes a heart rate of 118 beats per minute and a blood pressure of 88/52 mm Hg. The client's peripheral pulses are weak. What is the most appropriate next action for the nurse?

  1. Escalate these clinical findings to the registered nurse or healthcare provider immediately.Answer
  2. B
    Record the measurements in the chart and plan to reassess the client in one hour.
  3. C
    Provide oral fluids to help increase the client's circulatory volume.
  4. D
    Raise the head of the bed to a high-Fowler's position to improve cardiac output.

Answer

Escalate these clinical findings to the registered nurse or healthcare provider immediately.
Tachycardia, hypotension, and weak pulses in a postoperative client are critical indicators of hypovolemic shock or internal bleeding. The most appropriate action for the practical nurse is to immediately escalate these findings to the registered nurse or healthcare provider so emergency interventions can be initiated to restore circulatory volume.

Step-by-Step Solution

1
Analyze the client's postoperative vital signs.
The client has tachycardia (118 beats/min), hypotension (88/52 mm Hg), and weak peripheral pulses.
Identifying abnormal clinical data is the first step in risk reduction.
2
Correlate the findings with potential postoperative complications.
These findings are classic indicators of hypovolemia or internal hemorrhage.
Post-surgical clients are at high risk for fluid volume deficit and bleeding.
3
Determine the safest and most appropriate nursing action within the practical nurse's scope of practice.
The nurse must immediately inform the RN or provider.
Acute shock requires rapid advanced interventions, such as intravenous fluid resuscitation or blood transfusions, which must be initiated by the provider or RN.

Key Concept

Early Recognition and Escalation of Hypovolemic Shock
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Topics

Reduction of Risk Potential

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