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Difficulty: MediumPhysiological Adaptation

The nurse is reviewing the status of four clients on a medical-surgical step-down unit. Which client requires the most immediate assessment by the nurse?

  1. A client who underwent a percutaneous liver biopsy 4 hours ago and is now restless, with a heart rate of 108 bpm and a blood pressure of 106/82 mm Hg.Answer
  2. B
    A client with severe emphysema whose latest arterial blood gas results show a pH of 7.36, PaCO2 of 56 mm Hg, and HCO3 of 30 mEq/L.
  3. C
    A client admitted with viral gastroenteritis who has dry mucous membranes, a heart rate of 94 bpm, and a blood pressure of 98/60 mm Hg.
  4. D
    A client receiving a continuous heparin infusion for a deep vein thrombosis who has a partial thromboplastin time of 75 seconds and reports mild calf pain.

Answer

The client who underwent a percutaneous liver biopsy 4 hours ago and is now restless, with a heart rate of 108 bpm and a blood pressure of 106/82 mm Hg.
The correct answer identifies a client exhibiting early, subtle signs of hypovolemic shock due to internal bleeding, a critical complication following a highly vascular procedure like a percutaneous liver biopsy. Restlessness is often the earliest sign of hypoxia and decreased cerebral perfusion. Furthermore, a narrowing pulse pressure (106 - 82 = 24 mm Hg) occurs in early shock as the sympathetic nervous system initiates peripheral vasoconstriction, which raises the diastolic pressure to compensate for decreased cardiac output. This client requires immediate assessment and intervention to prevent profound shock.

Step-by-Step Solution

1
Analyze the clinical presentation of the client who had a liver biopsy.
The client is restless with a heart rate of 108 bpm and a pulse pressure of 24 mm Hg (106 - 82 = 24).
A highly vascular procedure like a liver biopsy carries a significant risk of bleeding. Restlessness, tachycardia, and a narrowing pulse pressure are classic early signs of hypovolemic shock.
2
Evaluate the arterial blood gas results for the client with emphysema.
The pH is normal (7.36), PaCO2 is elevated (56 mm Hg), and HCO3 is elevated (30 mEq/L).
This indicates fully compensated respiratory acidosis, which is an expected chronic baseline for severe emphysema and does not represent an acute decompensation.
3
Assess the stability of the client with viral gastroenteritis.
The client has slightly low blood pressure, dry mucous membranes, and an elevated heart rate.
While requiring intravenous or oral fluid replacement, these are signs of mild dehydration and do not indicate immediate life-threatening cardiovascular collapse.
4
Evaluate the status of the client receiving heparin therapy.
The partial thromboplastin time (PTT) is 75 seconds, and the client has mild calf pain.
A PTT of 75 seconds is within the therapeutic goal for heparin (1.5 to 2.5 times the control), and mild calf pain is expected with a deep vein thrombosis.
5
Prioritize the clients based on acuity and risk of imminent harm.
The client who underwent the liver biopsy is prioritized as the most critical.
Active internal bleeding leads to rapid decompensation and requires immediate life-saving interventions, making it the highest priority.

Key Concept

Prioritization and Early Recognition of Hypovolemic Shock
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Topics

Physiological Adaptation

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