During a morning assessment, a practical nurse evaluates a client who is 12 hours postoperative following a right total hip arthroplasty. The client appears mildly restless and reports a pain level of 4 on a 0 to 10 scale at the operative site. The current vital signs are a blood pressure of 104/64 mm Hg (baseline 134/78 mm Hg), a heart rate of 104 bpm, and a respiratory rate of 20/min. The morning hemoglobin level is reported as 6.9 g/dL (69 g/L). Which of the following is the most appropriate initial action for the nurse?
- Immediately report the client's status and morning blood work to the supervising registered nurse.Answer
- BAdminister the prescribed as-needed analgesic to address the reported surgical pain.
- CReassure the client and continue with the routine four-hour postoperative vital sign checks.
- DFile the laboratory value in the chart and verify that an afternoon blood draw is ordered.
Answer
The correct action is to immediately report the client's status and morning blood work to the supervising registered nurse.
The client is displaying a classic presentation of early hypovolemic shock due to postoperative hemorrhage. The combination of a significant drop in blood pressure from baseline, tachycardia, new-onset restlessness, and a critically low hemoglobin level (6.9 g/dL) indicates severely compromised circulation. Because managing complex, unstable clients and initiating blood transfusions fall outside the practical nurse's scope of independent practice, the most appropriate and immediate action is to report these critical findings to the supervising registered nurse for rapid medical intervention.
Step-by-Step Solution
Key Concept
Recognizing early signs of postoperative hemorrhage and hypovolemia