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Difficulty: Very hardPhysiological Adaptation

A 78-year-old client is 12 hours postoperative following a laparotomy and bowel resection. The practical nurse (PN) answers the call light and finds the client restless, repeatedly attempting to pull at their intravenous tubing, and stating that they are 'waiting for the bus.' The client's abdominal dressing is dry and intact. Vital signs are temperature 98.4°F (36.9°C), heart rate 114 beats/min, respiratory rate 24 breaths/min, and blood pressure 106/60 mm Hg. The preoperative blood pressure was 148/82 mm Hg. Which action should the PN take first?

  1. Elevate the client's lower extremities and immediately notify the registered nurse (RN).Answer
  2. B
    Administer the prescribed PRN analgesic, as restlessness often indicates uncontrolled pain.
  3. C
    Apply a bed alarm and verbally reorient the client to the hospital room environment.
  4. D
    Record the vital signs in the electronic health record, as they are within normal adult limits.

Answer

Elevate the client's lower extremities and immediately notify the registered nurse (RN).
The client is exhibiting early, classic signs of hypovolemic shock, likely due to internal hemorrhage following the laparotomy. Restlessness and acute confusion are often the earliest indicators of decreased cerebral perfusion. A heart rate of 114 beats/min and a blood pressure of 106/60 mm Hg (a significant drop of 42 mm Hg from the systolic baseline) represent compensatory tachycardia and relative hypotension. Because the abdominal dressing is dry, the bleeding is internal and masked. The priority action is to improve venous return and cardiac output by elevating the client's lower extremities and to immediately alert the registered nurse for collaborative medical interventions.

Step-by-Step Solution

1
Analyze the client's vital signs and compare them to the preoperative baseline data.
The heart rate is elevated (114 beats/min) and the blood pressure is significantly decreased from baseline (106/60 mm Hg down from 148/82 mm Hg), indicating relative hypotension.
Identifying relative changes, rather than just relying on absolute parameters, is crucial for recognizing early physiological decompensation.
2
Evaluate the client's neurological status and behavior in the context of recent surgery.
The client is exhibiting new-onset restlessness, disorientation, and agitation.
Acute changes in mental status are early, critical signs of decreased cerebral tissue perfusion associated with hypovolemic shock.
3
Synthesize the clinical findings to determine the priority physiological need.
The combined findings of tachycardia, relative hypotension, and acute confusion in a postoperative client indicate impending hypovolemic shock, likely from internal hemorrhage.
According to the ABCs (Airway, Breathing, Circulation) prioritization framework, circulation is severely and acutely compromised.
4
Select the nursing intervention that immediately addresses the circulation deficit while remaining within the PN scope of practice.
Elevating the client's legs increases venous return, and notifying the RN escalates the situation for rapid medical intervention.
This is the safest and most effective initial response to stabilize a client with suspected hemorrhagic shock.

Key Concept

Early recognition of hypovolemic shock requires comparing current vital signs to the client's baseline and interpreting acute mental status changes as indicators of poor cerebral perfusion.
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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