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Difficulty: EasyReduction of Risk Potential

An older adult client is receiving care for a history of peptic ulcer disease. The client suddenly appears pale and anxious. The practical nurse measures the client's vital signs and notes a heart rate of 124 beats per minute and a blood pressure of 96/52 mm Hg. Which of the following actions is the priority for the nurse?

  1. A
    Document the vital signs in the client's chart and reassess in one hour.
  2. B
    Ask the client to take slow, deep breaths to help lower the heart rate.
  3. Notify the registered nurse immediately regarding the client's condition.Answer
  4. D
    Review the client's admission laboratory results to identify a potential cause.

Answer

Notify the registered nurse immediately regarding the client's condition.
Tachycardia, hypotension, pallor, and anxiety are classic early signs of hypovolemic shock, which is a life-threatening complication of bleeding from a peptic ulcer. Within the practical nurse's scope of practice, the priority is to immediately notify the registered nurse or healthcare provider so that emergency fluid resuscitation and interventions can begin.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is pale, anxious, tachycardic (124 bpm), and hypotensive (96/52 mm Hg) with a history of peptic ulcer disease.
Recognizing abnormal assessment findings is the first step in clinical decision-making.
2
Correlate the findings to potential complications.
These vital signs and symptoms strongly indicate active internal bleeding and early hypovolemic shock.
Understanding the pathophysiology of peptic ulcer disease helps identify life-threatening risks.
3
Determine the practical nurse's scope of practice for this situation.
The nurse must immediately escalate the situation to the registered nurse or healthcare provider.
Timely communication is required to initiate emergency interventions and reduce the risk of severe harm.

Key Concept

Early recognition and escalation of hypovolemic shock
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Topics

Reduction of Risk Potential

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