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Difficulty: MediumReduction of Risk Potential

A client is recovering in the surgical unit 88 hours after a right total knee arthroplasty. The practical nurse evaluates the client and records a heart rate of 114114 beats/min, a blood pressure of 94/5694/56 mm Hg, and a respiratory rate of 1818 breaths/min. The client states their pain is currently manageable. Based on these findings, which of the following actions should the practical nurse take? Select all that apply.

  1. Inspect the surgical dressing and portable wound suction device for excessive blood accumulation.Answer
  2. Escalate the clinical assessment findings to the supervising registered nurse without delay.Answer
  3. Check the client's postoperative laboratory results for recent hemoglobin and hematocrit values.Answer
  4. D
    Chart the vital signs as a normal expected response to surgical stress and continue routine observations.
  5. E
    Position a folded pillow directly under the affected knee to promote client comfort and reduce swelling.
  6. F
    Flush the peripheral IV line and administer a small dose of intravenous push (IVP) analgesic.

Answer

The correct actions are to inspect the surgical dressing and wound suction device for bleeding, escalate the findings to the supervising registered nurse without delay, and check the postoperative hemoglobin and hematocrit laboratory results.
The client's tachycardia and hypotension postoperatively are early indicators of hypovolemia or internal bleeding. The practical nurse must prioritize client safety by assessing the surgical site for active bleeding, reviewing recent hemoglobin and hematocrit levels to evaluate blood loss, and immediately escalating these critical findings to the registered nurse for further medical management.

Step-by-Step Solution

1
Analyze the client's vital signs and postoperative timeline.
A heart rate of 114 beats/min and blood pressure of 94/56 mm Hg at 8 hours postoperative indicate potential early hypovolemic or hemorrhagic shock.
Tachycardia and mild hypotension are initial compensatory mechanisms when fluid or blood volume is actively being lost.
2
Determine the priority nursing interventions for suspected hypovolemia.
The nurse must identify the source of potential fluid loss by assessing the surgical site and gathering relevant laboratory data.
Assessing the surgical site for active bleeding and reviewing blood counts (Hgb/Hct) provide crucial data about the severity of blood loss.
3
Evaluate the role and scope of the practical nurse in this scenario.
The practical nurse must report these abnormal, potentially critical findings directly to the registered nurse.
Initiating emergency protocols and modifying the overall medical plan of care falls under the registered nurse's scope, requiring immediate collaboration.

Key Concept

Early recognition of hypovolemic shock and appropriate escalation within the practical nursing scope of practice.
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Reduction of Risk Potential

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