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Question

Difficulty: MediumReduction of Risk Potential

A client who underwent a transverse colectomy three days ago has a morning hemoglobin result of 7.9 g/dL. During the morning assessment, the nurse notes a heart rate of 115 beats per minute, a respiratory rate of 22 breaths per minute, and a blood pressure of 94/60 mm Hg. The client complains of new-onset lightheadedness when resting in bed. Which action is the priority for the nurse to implement?

  1. Notify the registered nurse immediately about the vital signs and laboratory results.Answer
  2. B
    Record the assessment data and recheck the client's blood pressure in one hour.
  3. C
    Give the client their scheduled oral iron tablet with breakfast to treat the anemia.
  4. D
    Teach the client to change positions slowly to minimize the feelings of lightheadedness.

Answer

The priority action is to immediately notify the registered nurse regarding the client's vital signs and hemoglobin levels.
The correct action demonstrates an understanding of risk reduction by promptly identifying clinical indicators of hypovolemic shock—such as a critically low hemoglobin, tachycardia, hypotension, and lightheadedness—and escalating the situation to the registered nurse for rapid medical intervention.

Step-by-Step Solution

1
Analyze the client's laboratory results and vital signs.
The hemoglobin is critically low (7.9 g/dL), accompanied by tachycardia, hypotension, and lightheadedness.
Recognizing the combination of these findings indicates an acute complication such as internal bleeding or hypovolemic shock.
2
Determine the scope of practice for the practical nurse in an emergent situation.
The practical nurse must immediately escalate the findings to the registered nurse or healthcare provider.
Acute physiological deterioration requires immediate RN-level assessment and potential medical intervention (such as blood transfusions or fluid resuscitation) to stabilize the client.

Key Concept

Identifying early signs of hypovolemia and escalating critical findings
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Topics

Reduction of Risk Potential

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