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Difficulty: MediumPhysiological Adaptation

A 45-year-old client is 6 hours post-operative following an abdominal hysterectomy. The client reports incisional pain rated as 7 on a 0 to 10 scale and appears increasingly restless. The practical nurse (PN) obtains the following vital signs: heart rate 116 beats/minute, blood pressure 100/60 mm Hg, respiratory rate 20 breaths/minute, and oxygen saturation 96% on room air. Which action should the PN take first?

  1. Check the surgical incision site and underneath the client for signs of hemorrhage.Answer
  2. B
    Give the client the requested oral analgesic to relieve the incisional pain.
  3. C
    Record the vital signs in the chart and continue routine post-operative monitoring.
  4. D
    Guide the client through deep breathing exercises to help reduce their anxiety and restlessness.

Answer

The priority action is to check the surgical incision site and underneath the client for signs of hemorrhage.
The correct answer correctly prioritizes data collection for a potential life-threatening complication. Tachycardia, restlessness, and borderline low blood pressure are early compensatory signs of hypovolemic shock due to hemorrhage. Following the ABCs (Airway, Breathing, Circulation), the nurse must first check for bleeding (circulation) before taking other actions.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client presents with tachycardia (116 bpm), borderline hypotension (100/60 mm Hg), and unexpected restlessness 6 hours after major surgery.
Identifying abnormal data points is the essential first step in clinical judgment.
2
Correlate the assessment findings with potential post-operative complications.
The combination of tachycardia, borderline low blood pressure, and restlessness strongly suggests early hypovolemic shock (likely due to internal or external bleeding) rather than just pain or anxiety.
Recognizing physiological adaptation to blood loss allows the nurse to anticipate life-threatening conditions.
3
Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).
The priority is to assess circulation by checking for active bleeding at the surgical site and pooling under the client.
Data collection regarding the most immediate life-threatening condition (circulation/shock) takes precedence over symptom management like pain relief.

Key Concept

Early recognition of hypovolemic shock and prioritization of circulatory assessment in post-operative clients.
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Topics

Physiological Adaptation

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