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Difficulty: MediumPhysiological Adaptation

A client with a confirmed gastric ulcer is being monitored on the medical-surgical unit. Over the last three hours, the practical nurse observes that the client's resting heart rate has steadily increased from 76 to 118 beats per minute, and the blood pressure has narrowed from 128/78 mm Hg to 112/88 mm Hg. The client is moving restlessly in bed and repeatedly asking for water. Which action should the practical nurse take first?

  1. A
    Record the observations in the electronic health record and reassess in one hour.
  2. Promptly alert the charge nurse about the changing vital sign trends.Answer
  3. C
    Provide a small cup of ice chips to relieve the client's reported thirst.
  4. D
    Dim the room lights and instruct the client to practice deep breathing for relaxation.

Answer

Promptly alert the charge nurse about the changing vital sign trends.
The client is demonstrating classic early signs of hypovolemic shock (the compensatory stage), including unexplained tachycardia, a narrowing pulse pressure, restlessness, and severe thirst, likely due to active gastrointestinal bleeding. The immediate priority is to escalate these findings to the charge nurse or provider so that rapid life-saving interventions, such as intravenous fluid resuscitation or blood products, can be initiated.

Step-by-Step Solution

1
Analyze the client's vital sign trends and physical presentation.
The increasing heart rate, narrowing pulse pressure, restlessness, and thirst indicate early compensatory hypovolemic shock due to potential active bleeding.
Identifying early signs of physiological deterioration is essential to prevent progression to irreversible shock.
2
Determine the appropriate priority action within the practical nurse's scope of practice.
The practical nurse must immediately escalate these critical findings to the supervising registered nurse or provider.
Acute hemodynamic instability requires advanced assessment and collaborative medical interventions beyond the independent scope of a practical nurse.

Key Concept

Recognition of Early Hypovolemic Shock
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Topics

Physiological Adaptation

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