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Question

Difficulty: EasyReduction of Risk Potential

A practical nurse is caring for a client who underwent a percutaneous kidney biopsy 3 hours ago. The client reports new-onset severe flank pain. The current vital signs are: heart rate 116 beats per minute and blood pressure 86/54 mm Hg. The morning laboratory report shows a hemoglobin level of 7.9 g/dL. Which action should the practical nurse take first?

  1. Promptly report the vital signs, pain assessment, and laboratory results to the registered nurse.Answer
  2. B
    Reassess the client's vital signs in one hour to determine if the blood pressure stabilizes on its own.
  3. C
    Document the hemoglobin level in the electronic health record and wait for the provider's routine afternoon rounds.
  4. D
    Delegate the task of evaluating the client's biopsy insertion site for bleeding to the assistive personnel.

Answer

The practical nurse must promptly report the vital signs, pain assessment, and laboratory results to the registered nurse.
The client is exhibiting classic signs of internal hemorrhage and hypovolemic shock (tachycardia, hypotension, severe localized pain, and low hemoglobin) following a highly vascular procedure (kidney biopsy). The practical nurse must immediately escalate these life-threatening findings to the registered nurse or healthcare provider to reduce the risk of severe complications and initiate emergency interventions.

Step-by-Step Solution

1
Analyze the client's post-procedure assessment data.
The client has severe flank pain, tachycardia (HR 116), hypotension (BP 86/54), and low hemoglobin (7.9 g/dL).
Identifying abnormal findings is the first step in recognizing potential post-procedure complications.
2
Correlate the findings with the specific risks of the procedure.
A kidney biopsy carries a high risk of hemorrhage. The findings point directly to internal bleeding and hypovolemic shock.
Understanding procedure-specific risks allows the nurse to prioritize care accurately.
3
Determine the safest and most appropriate nursing action within the practical nurse scope of practice.
Escalate the critical findings to the registered nurse or healthcare provider immediately.
Unstable clients experiencing life-threatening complications require immediate RN or provider intervention to mitigate risks.

Key Concept

Reduction of Risk Potential: Recognizing and Escaping Complications
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Topics

Reduction of Risk Potential

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