A surgical unit nurse is assessing a client who underwent a partial colectomy 8 hours ago. The client reports incisional pain rated as 4 on a 0 to 10 scale. Upon review of the electronic health record, the nurse notes the client's preoperative blood pressure was 128/76 mm Hg with a heart rate of 78 bpm. Current assessment reveals a blood pressure of 106/84 mm Hg, a heart rate of 116 bpm, and a respiratory rate of 22 breaths/min. Which action should the nurse take first?
- Initiate a prescribed intravenous isotonic fluid bolusAnswer
- BAdminister the prescribed as-needed intravenous opioid analgesic
- CRequest a prescription for an arterial blood gas analysis
- DInstruct the assistive personnel to measure vital signs every 15 minutes
Answer
Initiate a prescribed intravenous isotonic fluid bolus
The correct action directly addresses the client's circulatory compromise. A narrowing pulse pressure (the difference between systolic and diastolic pressure decreasing from 52 to 22 mm Hg) combined with tachycardia is a hallmark sign of early compensatory shock. As cardiac output drops, the body vasoconstricts to maintain blood pressure, which raises the diastolic number and keeps the systolic relatively stable initially. Administering an isotonic fluid bolus is the priority intervention to restore intravascular volume and maintain organ perfusion.
Step-by-Step Solution
Key Concept
Early indicators of hypovolemic shock include tachycardia and a narrowing pulse pressure, which require immediate fluid resuscitation to prevent irreversible organ damage.