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Difficulty: HardReduction of Risk Potential

An LPN is evaluating a client who underwent a laparoscopic cholecystectomy 6 hours ago. The client's preoperative blood pressure was 128/76 mm Hg with a heart rate of 72 beats/min. Current data collection reveals a blood pressure of 102/68 mm Hg, a heart rate of 104 beats/min, and a respiratory rate of 22 breaths/min. The client appears restless, and the indwelling urinary catheter has drained a total of 45 mL of urine over the past two hours. The surgical incisions are intact with trace serosanguinous drainage. Which of the following actions is the priority for the nurse to take?

  1. A
    Reassess the vital signs and urinary output in one hour to determine if a trend is developing.
  2. B
    Administer the prescribed as-needed anti-anxiety medication to treat the client's restlessness.
  3. Report the assessment data to the supervising registered nurse immediately.Answer
  4. D
    Independently increase the continuous intravenous fluid infusion rate to address the low urine output.

Answer

Report the assessment data to the supervising registered nurse immediately.
The client is exhibiting a classic presentation of early hypovolemic shock, characterized by tachycardia, a decreasing blood pressure compared to baseline, low urine output (less than 30 mL/hr), and restlessness (an early sign of decreased cerebral perfusion and hypoxia). The priority action for the practical nurse is to immediately report these critical findings to the registered nurse for advanced assessment and collaborative medical intervention.

Step-by-Step Solution

1
Analyze the preoperative baseline vital signs.
Baseline blood pressure was 128/76 mm Hg and heart rate was 72 beats/min.
Establishing a baseline is necessary to identify significant post-operative changes.
2
Evaluate the current vital signs and physical assessment findings against the baseline.
The blood pressure has dropped to 102/68 mm Hg, the heart rate has increased to 104 beats/min, urine output is low (22.5 mL/hr), and the client is restless.
Comparing current data to baseline reveals a pattern indicative of a developing complication, specifically decreased cardiac output and poor tissue perfusion.
3
Determine the underlying pathophysiology and prioritize the necessary nursing action.
The combination of tachycardia, dropping blood pressure, oliguria, and restlessness strongly suggests early hypovolemic shock, likely from internal bleeding.
Recognizing these subtle but critical signs allows the practical nurse to take immediate action within their scope.
4
Select the safest and most appropriate intervention based on the practical nurse's scope of practice.
The priority is to immediately escalate these critical findings to the registered nurse.
An unstable client requiring advanced clinical assessment and potential medical intervention must be managed by the registered nurse and healthcare provider.

Key Concept

Reduction of Risk Potential: Early Recognition of Complications and Scope of Practice
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Reduction of Risk Potential

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