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Difficulty: MediumReduction of Risk Potential

During the first 4 hours of postoperative care following a radical nephrectomy, a client's physiological parameters begin to shift. The initial postoperative assessment revealed a blood pressure of 138/76 mm Hg and a heart rate of 78 beats/min. The current assessment shows a blood pressure of 116/88 mm Hg, a heart rate of 115 beats/min, and a respiratory rate of 22 breaths/min. In response to these changes, which of the following interventions should the nurse prioritize?

  1. Increase the prescribed intravenous isotonic fluid rate and immediately contact the healthcare provider.Answer
  2. B
    Document the findings as expected postoperative variations and reassess the client in 60 minutes.
  3. C
    Delegate the collection of an arterial blood gas sample to the unlicensed assistive personnel.
  4. D
    Elevate the head of the bed to a high-Fowler's position to maximize respiratory excursion and venous return.

Answer

Increase the prescribed intravenous isotonic fluid rate and immediately contact the healthcare provider.
The correct answer addresses the client's transition into compensatory hypovolemic shock. A radical nephrectomy carries a high risk of hemorrhage. The client's pulse pressure has narrowed significantly (from 62 mm Hg to 28 mm Hg) and is accompanied by new-onset tachycardia. These are classic early signs of shock as the body attempts to maintain cardiac output. Increasing intravenous fluids helps restore intravascular volume, and immediate provider notification is critical for further medical or surgical intervention.

Step-by-Step Solution

1
Analyze the baseline vital signs compared to the current vital signs.
The client's pulse pressure narrowed from 62 mm Hg to 28 mm Hg, and the heart rate increased from 78 to 115 beats/min.
Identifying trends in vital signs is essential to detect early physiological decompensation before severe hypotension occurs.
2
Interpret the clinical significance of these vital sign changes in a postoperative client.
The combination of tachycardia and a narrowing pulse pressure indicates the compensatory stage of hypovolemic shock, likely due to internal hemorrhage.
A radical nephrectomy is a highly vascular procedure with a significant risk of postoperative bleeding.
3
Select the nursing intervention that directly mitigates this life-threatening risk.
Administering intravenous fluids and notifying the provider addresses the volume deficit and initiates necessary medical management.
Immediate action is required to prevent progression to decompensated shock and potential organ failure.

Key Concept

Early recognition and management of postoperative hypovolemic shock
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Topics

Reduction of Risk Potential

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