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Difficulty: Very hardReduction of Risk Potential

An adult client is recovering in the surgical observation unit four hours after undergoing a left percutaneous renal biopsy. The client's pre-procedure vital signs were a blood pressure of 134/76 mm Hg, an apical pulse of 72 beats/min, and a respiratory rate of 14 breaths/min. During the current assessment, the client reports a persistent, dull ache in the left lower back that radiates toward the anterior abdomen. The nurse obtains the following data: blood pressure is 112/86 mm Hg, apical pulse is 104 beats/min, and respiratory rate is 22 breaths/min. The client's urine output via Foley catheter is 40 mL over the past hour and appears pink-tinged. An arterial blood gas (ABG) sample drawn 15 minutes ago reveals a pH of 7.44, a PaCO2PaCO_2 of 32 mm Hg, and an HCO3−HCO_3^- of 21 mEq/L. Based on these assessment findings, which of the following actions should the nurse prioritize?

  1. Contact the healthcare provider immediately and prepare for isotonic fluid volume expansion.Answer
  2. B
    Help the client turn onto their right side to decrease mechanical pressure on the biopsy site.
  3. C
    Prepare to administer sodium bicarbonate to correct the client's uncompensated metabolic acidosis.
  4. D
    Record the pink-tinged urine and vital signs as expected early recovery findings.

Answer

The nurse must contact the healthcare provider immediately and prepare for isotonic fluid volume expansion to address impending hypovolemic shock.
The correct action prioritizes treating early hemorrhagic shock. A percutaneous renal biopsy carries a high risk of bleeding because the kidneys are extremely vascular. The client's vital signs show a transition from a baseline pulse pressure of 58 mm Hg to a narrow 26 mm Hg, accompanied by new-onset tachycardia. These are classic compensatory signs of hypovolemia. Combined with the persistent, radiating flank pain, these findings strongly indicate a retroperitoneal hemorrhage. The nurse must immediately alert the provider and prepare for volume resuscitation to prevent cardiovascular collapse.

Step-by-Step Solution

1
Analyze the vital sign trends to detect subtle physiological changes.
The pulse pressure has narrowed significantly from 134−76=58134 - 76 = 58 mm Hg to 112−86=26112 - 86 = 26 mm Hg, and the heart rate has increased from 72 to 104 beats/min.
Narrowing pulse pressure and tachycardia are the earliest compensatory mechanisms for volume depletion before frank hypotension occurs.
2
Correlate the hemodynamic changes with the subjective pain assessment.
The combination of compensatory shock signs and new, radiating flank pain strongly suggests a retroperitoneal hemorrhage at the biopsy site.
The kidneys are highly vascular, and bleeding into the retroperitoneal space can accommodate large volumes of blood with minimal initial external signs.
3
Interpret the arterial blood gas (ABG) values.
A pH of 7.44 and PaCO2PaCO_2 of 32 mm Hg indicates mild respiratory alkalosis, likely secondary to pain and tachypnea.
Accurate ABG interpretation prevents the administration of contraindicated medications like sodium bicarbonate.
4
Determine the highest priority nursing intervention.
Immediate medical notification and preparation for fluid resuscitation is required.
Internal hemorrhage is a medical emergency that requires prompt volume replacement and potentially surgical or interventional radiology repair.

Key Concept

Early recognition of retroperitoneal hemorrhage involves detecting narrowing pulse pressure, tachycardia, and radiating flank pain, which require immediate fluid resuscitation and medical intervention.
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Reduction of Risk Potential

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