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Difficulty: MediumReduction of Risk Potential

A nurse is caring for a 4545-year-old client who is 22 hours post-operative following an abdominal hysterectomy. Initial vital signs upon arrival to the unit were: blood pressure 118/76118/76 mm Hg, heart rate 8888 beats/min, and respiratory rate 1616 breaths/min. One hour later, the client's vital signs are: blood pressure 110/84110/84 mm Hg, heart rate 112112 beats/min, and respiratory rate 2222 breaths/min. The client reports feeling increasingly anxious and thirsty. Which of the following is the priority nursing action?

  1. Assess the abdominal surgical dressing and perineal pad for active bleeding.Answer
  2. B
    Elevate the head of the bed to a high-Fowler's position to help relieve the client's anxiety.
  3. C
    Instruct the unlicensed assistive personnel (UAP) to reassess the client's vital signs in 1515 minutes.
  4. D
    Document the vital signs in the electronic health record as expected postoperative findings.

Answer

The priority action is to assess the abdominal surgical dressing and perineal pad for active bleeding.
The correct answer is to assess the surgical dressing and perineal area for active bleeding. The client is exhibiting early compensatory signs of hypovolemic shock, indicated by a narrowing pulse pressure (from 4242 mm Hg down to 2626 mm Hg), tachycardia, tachypnea, anxiety, and thirst. The immediate priority is to identify the source of the hemorrhage so that targeted interventions can begin.

Step-by-Step Solution

1
Analyze the client's vital sign trends over time.
The pulse pressure has narrowed significantly from 4242 mm Hg to 2626 mm Hg, the heart rate has increased from 8888 to 112112 beats/min, and the respiratory rate has increased.
Comparing current hemodynamic data to baseline is essential for identifying early physiological deterioration.
2
Correlate the vital sign changes with the client's subjective symptoms.
The combination of a narrowing pulse pressure, tachycardia, tachypnea, anxiety, and thirst points to early, compensatory hypovolemic shock.
Subjective symptoms like anxiety and thirst are early clinical indicators of decreased tissue perfusion and oxygenation.
3
Determine the priority nursing action based on the assessment findings.
The nurse must immediately assess for the source of fluid or blood loss, which in this postoperative client is most likely the surgical site.
Identifying the active cause of hemorrhage is required before definitive medical interventions (like fluid resuscitation or returning to surgery) can be implemented.

Key Concept

Early recognition of hypovolemic shock and prioritization of assessments in the postoperative client.
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Topics

Reduction of Risk Potential

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