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Difficulty: MediumReduction of Risk Potential

An adult client is recovering on the surgical unit 3 hours after a septoplasty and turbinate reduction. During a routine assessment, the practical nurse observes that the client is swallowing frequently. The client's heart rate has increased to 118 beats per minute from a preoperative baseline of 76 beats per minute, and the blood pressure is 102/64 mmHg. Which action should the practical nurse take first?

  1. Immediately notify the registered nurse (RN) regarding the signs of potential bleeding.Answer
  2. B
    Administer the prescribed as-needed (PRN) analgesic to manage throat discomfort.
  3. C
    Place the client in a supine position with the head of the bed flat to stabilize blood pressure.
  4. D
    Document the frequent swallowing and vital signs as expected postoperative responses.

Answer

Immediately notify the registered nurse (RN) regarding the signs of potential bleeding.
The client's frequent swallowing, combined with an increasing heart rate and a decreasing blood pressure, strongly indicates active postoperative bleeding (hemorrhage) following nasal surgery. The priority action for the practical nurse is to immediately notify the registered nurse or healthcare provider so that the client can be assessed for airway compromise and shock, and emergency interventions can be initiated.

Step-by-Step Solution

1
Analyze the client's postoperative clinical presentation.
The client exhibits frequent swallowing, new-onset tachycardia, and borderline hypotension.
Identifying abnormal assessment findings is the first step in recognizing postoperative complications.
2
Correlate the findings with the specific surgical procedure.
After nasal surgery (septoplasty), frequent swallowing indicates blood draining down the back of the throat, while the vital signs suggest early hypovolemic shock.
Connecting symptoms to the procedure context reveals an active hemorrhage.
3
Determine the priority nursing action based on the LPN scope of practice.
The situation requires immediate escalation to the RN or healthcare provider for emergency intervention.
Active hemorrhage and early shock are life-threatening complications that exceed the scope of independent LPN management.

Key Concept

Early Recognition of Postoperative Hemorrhage
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Topics

Reduction of Risk Potential

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