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Difficulty: MediumPhysiological Adaptation

A licensed practical nurse (LPN) is assisting with the care of a client who had a laparoscopic cholecystectomy 4 hours ago. The client is currently agitated and repeatedly asking about their location. Current vital signs include a heart rate of 118 bpm, a respiratory rate of 24 breaths/min, and a blood pressure of 92/56 mm Hg. The client's admission blood pressure was 128/74 mm Hg. Which of the following is the priority action for the LPN?

  1. Notify the registered nurse (RN) immediately regarding the assessment findings.Answer
  2. B
    Offer the prescribed as-needed (PRN) analgesic to manage potential pain.
  3. C
    Provide frequent verbal reorientation and maintain a calm environment.
  4. D
    Record the current vital signs in the chart and reassess in one hour.

Answer

The priority action is to immediately notify the registered nurse (RN) regarding the assessment findings.
The correct action is to notify the RN immediately. The client's sudden agitation, increased heart rate, and decreased blood pressure compared to baseline are classic early signs of hypovolemic shock (potentially from internal bleeding). Within the LPN's scope of practice, recognizing acute physiological deterioration and rapidly escalating the information is the highest priority.

Step-by-Step Solution

1
Analyze the client's current clinical presentation against their baseline.
The client has a new onset of agitation, tachycardia (118 bpm), tachypnea (24 breaths/min), and a significant drop in blood pressure (92/56 mm Hg from 128/74 mm Hg).
Comparing current data to baseline is essential to identify trends indicative of physiological deterioration.
2
Correlate the findings to potential postoperative complications.
The combination of altered mental status, tachycardia, and hypotension strongly suggests early hypovolemic shock, likely due to internal bleeding.
Recognizing early signs of shock is a critical component of physiological adaptation and patient safety.
3
Determine the most appropriate action within the LPN scope of practice.
The LPN must immediately communicate these unstable findings to the RN for further assessment and collaborative intervention.
Acute, life-threatening changes require immediate escalation to ensure timely medical management.

Key Concept

Early recognition of shock and acute decompensation
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Topics

Physiological Adaptation

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