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Difficulty: HardReduction of Risk Potential

A practical nurse (PN) is assigned to care for a client who returned to the medical-surgical unit one hour ago following an esophagogastroduodenoscopy (EGD) with a gastric biopsy. The client is resting quietly and reports mild throat soreness. The PN records the following vital signs: blood pressure 106/62 mm Hg, heart rate 108 beats/minute, and respiratory rate 18 breaths/minute. The client's pre-procedure vital signs were blood pressure 144/82 mm Hg, heart rate 72 beats/minute, and respiratory rate 16 breaths/minute. Which action should the PN take first?

  1. Notify the supervising registered nurse immediately.Answer
  2. B
    Document the findings and reassess the vital signs in 30 minutes.
  3. C
    Prepare to administer a prescribed PRN liquid analgesic for the throat soreness.
  4. D
    Elevate the head of the bed to a high-Fowler's position to promote comfort.

Answer

The priority action is to immediately notify the supervising registered nurse about the client's vital sign changes.
The correct action is to immediately notify the registered nurse. The client's vital signs show a significant drop in blood pressure and a new onset of tachycardia compared to the baseline. Following an invasive procedure like an EGD with biopsy, these subtle but significant changes are classic early indicators of potential internal hemorrhage or perforation. The practical nurse must recognize this complication and prioritize immediate escalation over routine care.

Step-by-Step Solution

1
Compare the current vital signs to the pre-procedure baseline.
The systolic blood pressure dropped by 38 mm Hg, and the heart rate increased by 36 beats/minute.
Identifying significant deviations from baseline is essential for detecting early postoperative complications.
2
Correlate the vital sign trends with the recent invasive procedure.
The combination of new-onset tachycardia and a significant drop in blood pressure following a gastric biopsy strongly suggests internal bleeding.
An EGD with biopsy carries a specific risk of gastrointestinal hemorrhage or perforation.
3
Determine the priority nursing action within the practical nurse scope of practice.
The PN must immediately report these findings to the registered nurse for urgent assessment.
Critical changes in hemodynamic status require immediate RN intervention and provider notification.

Key Concept

Recognition and escalation of early postoperative hemorrhage indicators
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Topics

Reduction of Risk Potential

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