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Difficulty: Very hardReduction of Risk Potential

The practical nurse (PN) reviews the electronic health record (EHR) of a client admitted with an acute exacerbation of ulcerative colitis. The client is receiving continuous intravenous hydration and methylprednisolone.

Parameter04:00 (Previous)08:00 (Current)
Heart Rate88 bpm114 bpm
Blood Pressure118/76 mmHg102/64 mmHg
Temperature37.4°C (99.3°F)37.6°C (99.7°F)
Bowel Movements2 (liquid, bloody)4 (liquid, bright red)
Hemoglobin11.2 g/dL9.0 g/dL

Based on the clinical trajectory and current data, which action should the PN take first to reduce the client's risk for severe complications?

  1. Immediately alert the supervising registered nurse regarding the hemodynamic trends and recent hemoglobin resultAnswer
  2. B
    Document the findings in the electronic health record and reassess the client's vital signs in two hours
  3. C
    Prepare to administer the client's scheduled daily dose of subcutaneous enoxaparin
  4. D
    Instruct the unlicensed assistive personnel (UAP) to encourage the client to drink more oral fluids

Answer

Immediately alert the supervising registered nurse regarding the hemodynamic trends and recent hemoglobin result
The client is demonstrating classic early signs of hypovolemic shock due to acute gastrointestinal bleeding. The rapidly dropping hemoglobin (decrease of 2.2 g/dL in just 4 hours), paired with resting tachycardia (114 bpm) and a narrowing pulse pressure, clearly indicates active blood loss. The most critical action within the practical nurse scope is to immediately escalate these findings to the supervising registered nurse so that life-saving interventions can be initiated.

Step-by-Step Solution

1
Analyze the vital sign trends across the four-hour period.
The heart rate increased significantly from 88 to 114 bpm, while the blood pressure decreased from 118/76 to 102/64 mmHg.
Recognizing early compensatory mechanisms (tachycardia) is crucial for identifying impending hemodynamic instability.
2
Evaluate the laboratory data and physical output against the vital signs.
The hemoglobin dropped rapidly by 2.2 g/dL, which correlates with the increase in bright red bloody stools, confirming active internal hemorrhage.
Linking the objective lab data with the physical assessment findings provides the complete clinical picture of acute blood loss.
3
Determine the highest priority action within the practical nursing scope of practice.
Escalate the findings immediately to the registered nurse or healthcare provider.
Active hemorrhage leading to early hypovolemic shock requires advanced interventions (e.g., blood transfusions, massive fluid resuscitation) that necessitate immediate provider notification.

Key Concept

Recognition and Escalation of Early Hypovolemic Shock
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Topics

Reduction of Risk Potential

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