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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is monitoring a client admitted with acute gastroenteritis and frequent episodes of vomiting. During the most recent data collection, the PN notes the client's blood pressure has decreased from 124/80 mm Hg to 98/62 mm Hg, and the heart rate has increased from 86 beats/min to 118 beats/min. The client's skin is cool and clammy. Which action is the priority for the PN to take?

  1. Immediately report the clinical findings to the supervising registered nurse.Answer
  2. B
    Reassess the client's vital signs in 30 minutes to confirm the trend.
  3. C
    Offer the client oral rehydration fluids to help replace volume losses.
  4. D
    Administer the prescribed as-needed oral antiemetic medication.

Answer

The priority action is to immediately report the clinical findings to the supervising registered nurse.
The client is exhibiting classic signs of hypovolemic shock, including tachycardia, hypotension, and cool, clammy skin, resulting from severe fluid volume loss. The priority for the practical nurse is to recognize this acute physiological decompensation and immediately notify the supervising registered nurse or healthcare provider so that rapid interventions, such as intravenous fluid resuscitation, can be initiated to stabilize the client's circulation.

Step-by-Step Solution

1
Analyze the client's current vital signs and physical assessment data.
The client has sudden hypotension (98/62 mm Hg), tachycardia (118 beats/min), and cool, clammy skin following severe fluid loss.
Identifying abnormal data is the first step in recognizing physiological decompensation.
2
Correlate the findings with potential complications of the client's diagnosis.
The findings indicate a transition into hypovolemic shock due to excessive fluid loss from gastroenteritis.
Understanding the clinical picture allows the nurse to determine the urgency of the situation.
3
Determine the appropriate intervention within the practical nurse's scope of practice.
The PN must immediately communicate these critical findings to the RN or healthcare provider.
Hypovolemic shock requires rapid medical intervention, such as intravenous fluid resuscitation, which must be initiated by the RN or provider based on the PN's urgent report.

Key Concept

Recognition and Escalation of Hypovolemic Shock
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Topics

Physiological Adaptation

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