Examkin

Question

Difficulty: EasyReduction of Risk Potential

A practical nurse (PN) is evaluating a client two hours after a percutaneous liver biopsy. Which assessment finding requires immediate notification to the registered nurse (RN)?

  1. A heart rate of 115 beats/min and a blood pressure of 88/56 mm HgAnswer
  2. B
    Client report of right shoulder pain rated as 3 on a 0 to 10 scale
  3. C
    A single, dry pinpoint spot of blood on the outer pressure dressing
  4. D
    An oral temperature of 99.2°F (37.3°C)

Answer

The finding of a heart rate of 115 beats/min and a blood pressure of 88/56 mm Hg requires immediate reporting to the RN.
The correct answer identifies tachycardia and hypotension as early signs of hypovolemic shock. Hemorrhage is a major life-threatening complication of a liver biopsy. These vital signs demand immediate escalation to the registered nurse to prevent further decompensation.

Step-by-Step Solution

1
Analyze the client's recent procedure.
The client underwent a percutaneous liver biopsy, a procedure with a high risk of hemorrhage because the liver is extremely vascular.
Identifying the specific procedure helps anticipate the most dangerous potential complications.
2
Evaluate each assessment finding against expected post-procedure outcomes.
Mild referred pain, slight temperature elevation, and a dry spot of blood are expected or non-emergent findings. The elevated heart rate and low blood pressure indicate cardiovascular compromise.
Differentiating between expected benign findings and signs of clinical deterioration is essential for prioritizing nursing care.
3
Determine the priority action based on the findings.
The abnormal vital signs indicate early hypovolemic shock, requiring immediate escalation to the registered nurse or healthcare provider.
Early intervention in shock prevents severe client harm and potential mortality.

Key Concept

Early recognition of hypovolemic shock following vascular procedures
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic