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Difficulty: MediumPhysiological Adaptation

During rounding, a nurse evaluates a client who underwent an open abdominal surgery 10 hours ago. The client reports mild nausea and generalized weakness. The nurse compares the current vital signs to the assessment obtained four hours prior:

Parameter4 Hours AgoCurrent
Heart Rate78 beats/min114 beats/min
Blood Pressure126/74 mm Hg108/84 mm Hg
Respiratory Rate16 breaths/min24 breaths/min
Temperature98.6°F (37°C)98.2°F (36.8°C)

Based on these clinical findings, what is the priority nursing action?

  1. Inspect the surgical dressing and closed-suction drains for sanguineous output.Answer
  2. B
    Administer the prescribed as-needed antiemetic medication to relieve the client's nausea.
  3. C
    Request a prescription for an arterial blood gas analysis to evaluate the tachypnea.
  4. D
    Apply supplemental oxygen via nasal cannula to address the increased respiratory rate.

Answer

The priority action is to inspect the surgical dressing and drains for excessive sanguineous drainage to assess for postoperative hemorrhage.
The correct action directly addresses the most critical potential complication. The client's pulse pressure narrowed from 52 mm Hg (126 - 74) to 24 mm Hg (108 - 84), accompanied by tachycardia and tachypnea. This triad indicates the compensatory stage of hypovolemic shock. Direct assessment of the surgical site for hemorrhage is the immediate priority.

Step-by-Step Solution

1
Analyze the vital sign trends over the four-hour period.
The heart rate increased significantly (tachycardia), the respiratory rate increased (tachypnea), and the blood pressure demonstrates a narrowing pulse pressure (systolic decreased while diastolic increased).
Comparing current data to baseline is essential to detect clinical deterioration.
2
Correlate the vital sign changes with the client's postoperative status.
A narrowing pulse pressure combined with tachycardia in a postoperative client strongly suggests compensatory hypovolemic shock due to internal or external bleeding.
During early blood loss, the sympathetic nervous system triggers vasoconstriction, raising diastolic pressure, while decreased stroke volume lowers systolic pressure.
3
Determine the priority nursing intervention based on the clinical picture.
The nurse must immediately assess the surgical site and any drains to confirm or rule out active hemorrhage before initiating other symptomatic treatments.
Identifying the source of bleeding is required to implement definitive, life-saving interventions.

Key Concept

Early recognition of hypovolemic shock using pulse pressure trends
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Topics

Physiological Adaptation

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