Examkin

Question

Difficulty: MediumReduction of Risk Potential

During a shift on a surgical unit, a practical nurse is evaluating a client who underwent a partial nephrectomy 4 hours4\text{ hours} ago. The client's current vital signs include a heart rate of 116 beats/min116\text{ beats/min} and a blood pressure of 94/58 mm Hg94/58\text{ mm Hg}. The electronic health record displays a recent postoperative serum hemoglobin level of 11.0 g/dL11.0\text{ g/dL}. The client is awake and reporting moderate incisional pain. Which action should the practical nurse take first?

  1. Notify the registered nurse immediately regarding the client's current vital signs.Answer
  2. B
    Document the assessment data and plan to recheck the vital signs in one hour.
  3. C
    Page the healthcare provider to urgently report the postoperative hemoglobin level.
  4. D
    Assign the unlicensed assistive personnel (UAP) to examine the surgical dressing for active bleeding.

Answer

The practical nurse must immediately notify the registered nurse about the abnormal vital signs.
The correct action prioritizes airway, breathing, and circulation (ABC) principles. Tachycardia combined with borderline hypotension in a client recovering from a highly vascular surgery (partial nephrectomy) strongly suggests acute hemorrhage and early hypovolemic shock. The practical nurse must recognize this life-threatening risk potential and immediately escalate the findings to the registered nurse for rapid intervention.

Step-by-Step Solution

1
Analyze the client's vital signs in the context of the postoperative timeline.
The heart rate of 116 beats/min116\text{ beats/min} and blood pressure of 94/58 mm Hg94/58\text{ mm Hg} represent a significant deviation from expected stability for a client 4 hours4\text{ hours} post-nephrectomy.
Identifying subtle deviations in baseline vital signs is the first step in recognizing physiological instability.
2
Evaluate the laboratory data and client symptoms.
The hemoglobin is mildly low (11.0 g/dL11.0\text{ g/dL}) but anticipated after surgery, and moderate pain is a normal postoperative finding.
Differentiating between expected postoperative findings and emergent complications prevents incorrect prioritization.
3
Correlate the abnormal vital signs with surgical risk factors.
The unexplained tachycardia and borderline hypotension point to early hypovolemic shock, strongly suggesting hemorrhage at the highly vascular kidney surgical site.
Understanding the physiological implications of specific procedures helps anticipate severe complications.
4
Determine the safest priority action within the practical nursing scope of practice.
The nurse must escalate this critical change in condition to the registered nurse for advanced assessment and collaborative intervention.
Timely communication of a deteriorating client status is essential to reduce the risk of adverse physiological outcomes.

Key Concept

Early Recognition of Hypovolemic Shock and Timely Escalation
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic