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Difficulty: HardPhysiological Adaptation

While conducting a shift assessment on a surgical unit, the nurse evaluates a client who is 6 hours post-operative following a total abdominal hysterectomy. The electronic health record shows the client's blood pressure was 134/76 mm Hg two hours ago, but it is currently 112/88 mm Hg. The apical pulse has risen from 82 to 116 beats per minute, and respirations are 26 per minute. The client's skin is cool to the touch, and they report feeling unusually anxious. What is the priority nursing intervention?

  1. A
    Instruct the client to take slow, deep breaths to correct suspected respiratory alkalosis.
  2. B
    Document the findings and plan to reassess the vital signs in one hour since the systolic pressure is above 100 mm Hg.
  3. Administer a prescribed bolus of intravenous isotonic crystalloid fluids.Answer
  4. D
    Elevate the head of the bed to a high-Fowler's position to ease the client's respiratory effort.

Answer

Administer a prescribed bolus of intravenous isotonic crystalloid fluids.
The client is exhibiting classic signs of early compensatory hypovolemic (hemorrhagic) shock. The narrowing pulse pressure (decreasing from 58 to 24 mm Hg), tachycardia, tachypnea, cool skin, and new-onset anxiety indicate decreasing cardiac output and massive peripheral vasoconstriction. The immediate priority is to restore intravascular volume with isotonic fluids to maintain tissue perfusion while preparing to identify and treat the source of bleeding.

Step-by-Step Solution

1
Analyze the vital sign trends to identify the underlying physiological process.
The blood pressure shows a narrowing pulse pressure (decreasing from 58 mm Hg to 24 mm Hg). Combined with tachycardia, tachypnea, cool skin, and anxiety, this indicates early compensatory hypovolemic (hemorrhagic) shock.
Recognizing early compensatory mechanisms is crucial before irreversible end-organ damage occurs.
2
Determine the highest priority need based on the pathophysiological state.
The primary issue is a critical loss of intravascular volume leading to decreased tissue perfusion.
According to the ABCs (Airway, Breathing, Circulation), restoring circulating blood volume is the immediate circulatory priority in hypovolemic shock.
3
Select the appropriate nursing intervention to address the priority need.
Administering isotonic crystalloid fluids is the standard first-line treatment to expand intravascular volume and improve cardiac output.
Fluid resuscitation directly addresses the absolute hypovolemia caused by post-operative bleeding.

Key Concept

Early recognition and management of hypovolemic shock
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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