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Difficulty: HardReduction of Risk Potential

A nurse is evaluating a 58-year-old client who underwent a percutaneous left renal biopsy 44 hours ago. The client is increasingly difficult to arouse. Current vital signs reveal a heart rate of 122 beats/min122 \text{ beats/min}, blood pressure of 88/54 mm Hg88/54 \text{ mm Hg}, and respiratory rate of 24 breaths/min24 \text{ breaths/min}. The client's abdomen appears taut and distended. Recent arterial blood gas (ABG) results on room air demonstrate a pH\text{pH} of 7.287.28, PaCO2\text{PaCO}_2 of 32 mm Hg32 \text{ mm Hg}, and HCO3−\text{HCO}_3^- of 15 mEq/L15 \text{ mEq/L}. Which nursing action is the highest priority to reduce the client's risk of further physiological decompensation?

  1. A
    Prepare to administer an intravenous alkalizing agent to specifically treat the client's acute respiratory acidosis.
  2. Activate the rapid response team and prepare for immediate isotonic intravenous fluid resuscitation.Answer
  3. C
    Position the client upright at a 60∘60^\circ angle to optimize diaphragmatic excursion and enhance tissue oxygenation.
  4. D
    Palpate the distended abdomen to evaluate the extent of rigidity prior to auscultating for bowel sounds.

Answer

The highest priority action is to activate the rapid response team and prepare for immediate isotonic intravenous fluid resuscitation.
The client's tachycardia, hypotension, lethargy, and distended abdomen following a renal biopsy strongly indicate retroperitoneal or intra-abdominal hemorrhage. The arterial blood gas values reflect partially compensated metabolic acidosis, a consequence of lactic acid accumulation from poor tissue perfusion (shock). The most urgent priority is to stabilize the client's hemodynamic status by activating the rapid response team and restoring intravascular volume with isotonic fluids.

Step-by-Step Solution

1
Analyze the client's vital signs and physical assessment findings.
The client has tachycardia, hypotension, lethargy, and a taut, distended abdomen.
These are classic signs of internal hemorrhage and impending hypovolemic shock, which is a major complication following a percutaneous renal biopsy.
2
Interpret the arterial blood gas (ABG) results in the context of the clinical picture.
The pH\text{pH} of 7.287.28 indicates acidosis, and the low HCO3−\text{HCO}_3^- of 15 mEq/L15 \text{ mEq/L} confirms it is a primary metabolic acidosis. The slightly low PaCO2\text{PaCO}_2 of 32 mm Hg32 \text{ mm Hg} represents partial respiratory compensation.
Metabolic acidosis in this scenario is driven by lactic acid accumulation secondary to poor tissue perfusion from shock.
3
Determine the priority nursing intervention based on the physiological data.
Hemodynamic stabilization through volume resuscitation is required immediately.
Without adequate circulating volume, tissue perfusion will continue to decline, leading to irreversible shock and cardiopulmonary arrest.

Key Concept

Post-procedure hemorrhage recognition and hypovolemic shock management
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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