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Difficulty: Very hardPhysiological Adaptation

An adult client who underwent an open partial gastrectomy earlier in the day activates the call bell. The client states, "I feel incredibly thirsty and my heart is racing," while repeatedly pulling at the bed linens. Data collection reveals a temperature of 98.9°F (37.2°C), heart rate of 118 beats/minute, respiratory rate of 24 breaths/minute, and blood pressure of 102/82 mm Hg. Which of the following interventions should the practical nurse implement? Select all that apply.

  1. Apply a continuous pulse oximeter and verify the patency of the intravenous line.Answer
  2. Position the client flat in bed with the lower extremities elevated.Answer
  3. C
    Provide small sips of water or ice chips to address the client's severe thirst.
  4. D
    Administer the prescribed as-needed opioid analgesic to decrease the client's restlessness.
  5. Immediately report the data collection findings to the supervising registered nurse.Answer
  6. F
    Reassess the vital signs in two hours, as these are expected early postoperative values.

Answer

The correct actions are to apply continuous pulse oximetry while verifying intravenous access, position the client flat with elevated legs, and immediately report the findings to the registered nurse.
The client is demonstrating classic signs of early compensatory hypovolemic shock, likely secondary to internal hemorrhage following major abdominal surgery. The dangerously narrow pulse pressure (102 - 82 = 20 mm Hg), tachycardia, tachypnea, intense thirst, and restlessness (cerebral hypoperfusion) demand immediate action. The practical nurse must prioritize oxygenation and circulatory support by applying pulse oximetry, ensuring a patent IV line for imminent fluid resuscitation, positioning the client to maximize venous return to vital organs (flat with legs elevated), and immediately escalating the situation to the registered nurse.

Step-by-Step Solution

1
Analyze the vital signs and physical cues.
The blood pressure of 102/82 mm Hg reveals a narrow pulse pressure of 20 mm Hg. This, combined with tachycardia (118 beats/min), tachypnea, severe thirst, and restlessness, indicates early compensatory hypovolemic shock.
Recognizing subtle signs of shock is required before appropriate interventions can be selected.
2
Evaluate the clinical context of the symptoms.
The client recently underwent major abdominal surgery (partial gastrectomy), making internal hemorrhage the most likely cause of the hypovolemia.
Connecting the surgical history to the vital signs prevents misinterpreting the restlessness as simply postoperative pain or anxiety.
3
Select interventions within the practical nursing scope of practice.
Appropriate actions include promoting venous return (supine with legs elevated), preparing for fluid resuscitation (verifying IV patency), monitoring oxygenation, and rapid escalation to the RN.
The PN must protect airway/breathing/circulation (ABC) and collaborate with the RN for advanced interventions.

Key Concept

Early Recognition and Prioritization in Compensatory Hypovolemic Shock
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Topics

Physiological Adaptation

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