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Difficulty: MediumPhysiological Adaptation

During afternoon rounds, a client who underwent a percutaneous liver biopsy three hours ago reports feeling unusually thirsty and lightheaded. The practical nurse obtains the following vital signs: heart rate 114 bpm, blood pressure 96/58 mm Hg, and respiratory rate 22 breaths/min. The client's baseline blood pressure prior to the procedure was 128/74 mm Hg. Based on these findings, which action should the nurse take first?

  1. Notify the supervising registered nurse immediately.Answer
  2. B
    Document the vital signs in the electronic health record and reassess in one hour.
  3. C
    Ask the client to rate their current level of discomfort at the biopsy puncture site.
  4. D
    Assist the client into a high Fowler's position to alleviate the feeling of lightheadedness.

Answer

The correct action is to notify the supervising registered nurse immediately.
The correct response demonstrates the practical nurse's ability to recognize a life-threatening physiological adaptation (internal bleeding leading to hypovolemic shock) and take the appropriate priority action within their scope of practice, which is immediate escalation to the registered nurse.

Step-by-Step Solution

1
Analyze the client's presenting symptoms and vital signs against their baseline.
The client has developed tachycardia (114 bpm), hypotension (drop from 128/74 to 96/58), thirst, and lightheadedness.
Identifying acute changes from baseline is essential for early recognition of postoperative complications.
2
Correlate the findings with the recent procedure (liver biopsy).
The liver is highly vascular, making internal hemorrhage a primary risk following a biopsy. The symptoms directly align with hypovolemic shock.
Connecting physiological data to the client's clinical history helps determine the severity and nature of the emergency.
3
Determine the priority nursing action based on the practical nurse scope of practice.
The most critical action is to immediately escalate the findings to the registered nurse or healthcare provider.
Acute physiological decompensation requires immediate advanced intervention (such as IV fluids, blood products, or surgery) which must be initiated by the RN or provider.

Key Concept

Early Recognition of Hypovolemic Shock Post-Procedure
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Topics

Physiological Adaptation

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