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Difficulty: MediumPhysiological Adaptation

A practical nurse is caring for a 65-year-old client who underwent a total abdominal hysterectomy 4 hours ago. The client becomes restless, reports feeling dizzy, and states, "I am extremely thirsty." Baseline vital signs upon arrival to the unit were blood pressure 124/76 mm Hg, heart rate 82 beats/min, and respiratory rate 16 breaths/min. Current vital signs are blood pressure 104/66 mm Hg, heart rate 110 beats/min, and respiratory rate 22 breaths/min. The visible abdominal dressing is dry and intact. Which action should the practical nurse take first?

  1. A
    Offer the client a small cup of ice chips to alleviate the severe thirst.
  2. B
    Document the vital signs as an expected physiological response to surgical pain.
  3. Inspect the perineal pad and the linens beneath the client for pooling blood.Answer
  4. D
    Reassure the client that restlessness and dizziness are normal lingering effects of anesthesia.

Answer

The practical nurse should first inspect the perineal pad and the linens beneath the client for pooling blood.
The client is exhibiting classic early signs of hypovolemic shock, including restlessness, dizziness, excessive thirst, tachycardia, and a narrowing pulse pressure with hypotension. Since the visible abdominal dressing is dry, the practical nurse must assess for dependent pooling of blood under the client and check the perineal pad for hidden vaginal bleeding. Gathering this complete data is essential before immediately escalating the findings to the registered nurse.

Step-by-Step Solution

1
Analyze the client's vital signs and reported symptoms.
The client has developed tachycardia, mild hypotension, tachypnea, restlessness, dizziness, and extreme thirst compared to baseline.
Comparing current data to baseline is necessary to identify acute changes in condition.
2
Interpret the clinical significance of the changes.
These findings are classic early compensatory mechanisms for hypovolemic shock, likely due to postoperative hemorrhage.
Early recognition of shock is critical for preventing irreversible organ damage.
3
Determine the appropriate focused data collection.
Since the visible abdominal dressing is dry, the nurse must check for hidden bleeding by inspecting the perineal pad and underneath the client.
Blood follows gravity, so dependent pooling or vaginal bleeding are common sources of unseen hemorrhage after a hysterectomy.
4
Prioritize the immediate nursing action.
The practical nurse collects this critical data to complete the assessment before immediately escalating the findings to the registered nurse and provider.
The registered nurse needs complete assessment data to initiate emergency interventions.

Key Concept

Early recognition of hypovolemic shock and prioritization of data collection for hidden hemorrhage.
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Topics

Physiological Adaptation

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