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Difficulty: MediumPhysiological Adaptation

A nurse is evaluating a client who had an open abdominal surgery 6 hours ago. The client reports feeling dizzy, anxious, and extremely thirsty. The nurse assesses the vital signs: heart rate 124 beats/min, blood pressure 98/74 mm Hg (baseline 130/80 mm Hg), and respiratory rate 24 breaths/min. The client's skin is pale and cool to the touch. Which of the following is the priority nursing action?

  1. Position the client supine with the legs elevated and notify the healthcare provider.Answer
  2. B
    Administer the prescribed intravenous opioid analgesic to manage the client's anxiety and discomfort.
  3. C
    Draw a sample for arterial blood gas analysis to assess for the development of metabolic acidosis.
  4. D
    Provide the client with small sips of clear liquids to alleviate the reports of extreme thirst.

Answer

Position the client supine with the legs elevated and notify the healthcare provider.
The client is exhibiting hallmark signs of early hypovolemic (hemorrhagic) shock, including tachycardia, a narrowed pulse pressure, tachypnea, pale and cool skin, dizziness, and extreme thirst. The body's compensatory mechanisms are attempting to maintain organ perfusion. The immediate priority is to enhance venous return to the heart by positioning the client supine with legs elevated (modified Trendelenburg) and to notify the healthcare provider immediately for further life-saving orders, such as intravenous fluid resuscitation or blood products.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client has tachycardia, a narrowed pulse pressure (24 mm Hg), tachypnea, pale/cool skin, dizziness, and extreme thirst.
To identify deviations from baseline and recognize signs of physiological deterioration.
2
Correlate the findings with potential postoperative complications.
These findings are classic indicators of early hypovolemic (hemorrhagic) shock due to internal bleeding.
Tachycardia and peripheral vasoconstriction (pale/cool skin) are compensatory mechanisms attempting to maintain cardiac output.
3
Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).
The immediate priority is to support circulation and venous return while obtaining medical intervention.
Hypovolemic shock is a life-threatening emergency requiring rapid fluid resuscitation and potential surgical exploration.

Key Concept

Recognition and initial management of hypovolemic shock
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Topics

Physiological Adaptation

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