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Difficulty: MediumReduction of Risk Potential

A nurse is caring for a client who underwent a left-sided partial nephrectomy four hours ago. Over the past two hours, the client's heart rate has increased from 84 to 110 beats per minute, blood pressure has narrowed from 134/76 to 108/82 mm Hg, and urine output has decreased to 20 mL over the last hour. The client reports mild incisional pain. Which action should the nurse perform next?

  1. Inspect the dependent flank area and surgical dressing for pooling blood.Answer
  2. B
    Administer the prescribed intravenous analgesic to manage the client's reported pain.
  3. C
    Elevate the head of the bed to a high-Fowler's position to promote optimal oxygenation.
  4. D
    Delegate hourly urine output measurements and vital sign monitoring to the unlicensed assistive personnel.

Answer

The nurse should first inspect the dependent flank area and surgical dressing for pooling blood.
The client is demonstrating early signs of compensatory hypovolemic shock (tachycardia, narrowing pulse pressure, and decreased urine output), which is a critical risk following a highly vascular procedure like a partial nephrectomy. Because the kidneys are located in the retroperitoneal space, post-operative hemorrhage often pools dependently in the flank area or back rather than immediately saturating the anterior surgical dressing. The nurse's immediate priority is to assess for the source of bleeding to gather accurate clinical data before notifying the healthcare provider.

Step-by-Step Solution

1
Analyze the client's vital sign trends and physiological data.
The client exhibits newly onset tachycardia, a narrowing pulse pressure (from 58 to 26 mm Hg), and oliguria.
These findings represent early, compensatory signs of hypovolemic shock rather than isolated incisional pain.
2
Correlate the clinical findings with the surgical procedure.
The client had a partial nephrectomy, a highly vascular procedure in the retroperitoneal space.
Post-operative hemorrhage is a major complication, and blood may pool dependently in the flank area without showing on the anterior surgical dressing.
3
Determine the highest priority nursing action.
The nurse must gather direct assessment data regarding the bleeding source before notifying the provider or implementing other treatments.
Applying the nursing process requires assessment prior to intervention, especially to prevent complications related to risk potential.

Key Concept

Early recognition of hypovolemic shock and prioritization of focused post-operative assessments.
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Topics

Reduction of Risk Potential

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