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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is participating in the care of a client recovering from a colonoscopy with polyp removal performed earlier in the day. The client rings the call bell and reports severe, unrelenting abdominal cramping and nausea. Upon data collection, the PN notes the client's skin is cool to the touch, and the radial pulse is 118 beats per minute and thready. Which action should the PN take immediately?

  1. Notify the registered nurse (RN) about the assessment findings.Answer
  2. B
    Administer the prescribed as-needed antiemetic medication.
  3. C
    Reassure the client that cramping is a typical effect of the procedure.
  4. D
    Assist the client into a sitting position on the edge of the bed.

Answer

Notify the registered nurse (RN) about the assessment findings.
The client is exhibiting signs of a potential bowel perforation and internal bleeding (severe cramping, cool skin, tachycardia, thready pulse). Because this is a life-threatening emergency requiring advanced assessment and medical intervention, the priority action within the practical nurse's scope of practice is to immediately escalate the findings to the registered nurse.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has severe abdominal cramping, cool skin, and a rapid, thready pulse following an invasive procedural intervention.
Identifying abnormal physiological findings is the first step in clinical decision-making.
2
Determine the potential underlying complication.
These manifestations strongly suggest bowel perforation and developing hypovolemic shock, which is a medical emergency.
Early recognition of life-threatening procedural complications is essential for client safety and physiological adaptation.
3
Select the appropriate PN intervention based on the scope of practice.
The PN must immediately communicate these critical findings to the RN.
The client requires RN-level assessment and likely emergency medical intervention that exceeds the PN scope of practice.

Key Concept

Recognizing Procedural Complications and Shock
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Topics

Physiological Adaptation

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