Examkin

Question

Difficulty: EasyReduction of Risk Potential

A practical nurse is collecting data on a client who is 3 hours postoperative following abdominal surgery. Which of the following assessment findings should the nurse immediately report to the registered nurse as a potential early indicator of internal bleeding?

  1. Heart rate increasing from 76 to 112 beats/minAnswer
  2. B
    Blood pressure increasing from 122/80 to 138/88 mm Hg
  3. C
    Temperature slightly elevating to 99.4°F (37.4°C)
  4. D
    Client reporting an incisional pain level of 5 on a 0-to-10 scale

Answer

Heart rate increasing from 76 to 112 beats/min
In the early stages of internal bleeding (hypovolemic shock), the body's primary compensatory mechanism is to increase the heart rate to maintain cardiac output and adequate tissue perfusion. A sudden or steady increase in heart rate (tachycardia) is often the first vital sign change indicating fluid volume loss and must be reported immediately to prevent further deterioration.

Step-by-Step Solution

1
Identify the complication being asked about in the scenario.
The question asks for an early indicator of internal bleeding, which leads to hypovolemic shock.
Understanding the specific complication helps filter out normal, expected postoperative findings.
2
Recall the physiological response to internal blood loss.
The body compensates for reduced blood volume by increasing the heart rate (tachycardia) to maintain blood flow and oxygen delivery to tissues.
Tachycardia is often the very first measurable vital sign change in early shock.
3
Evaluate the given assessment findings against this physiological response.
An increasing heart rate to 112 beats/min indicates tachycardia. The other findings (mild fever, moderate pain, increased blood pressure) represent expected surgical responses or contradict the signs of shock.
This confirms that the elevated heart rate is the critical finding to report.

Key Concept

Early Signs of Hypovolemic Shock
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic