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Question

Difficulty: HardPhysiological Adaptation

A nurse is evaluating a client four hours after a percutaneous liver biopsy. The client now reports a new onset of dull right shoulder pain. The nurse reviews the client's vital sign trends:

ParameterBaselineCurrent
Blood Pressure128/82128/82 mm Hg112/86112/86 mm Hg
Heart Rate7676 beats/min108108 beats/min
Respiratory Rate1616 breaths/min2424 breaths/min

Which of the following actions should the nurse take first?

  1. Prepare for immediate administration of isotonic intravenous fluids and alert the healthcare provider.Answer
  2. B
    Administer the prescribed as-needed analgesic to alleviate the client's right shoulder pain.
  3. C
    Assist the client into a high Fowler's position to address the increased respiratory rate.
  4. D
    Reassess the client's vital signs in one hour while continuing routine post-procedure monitoring.

Answer

The priority action is to prepare for immediate administration of isotonic intravenous fluids and alert the healthcare provider due to signs of internal hemorrhage.
The client is exhibiting classic signs of early hypovolemic shock due to internal hemorrhage following a liver biopsy. The new-onset right shoulder pain is a classic presentation of referred pain from phrenic nerve irritation caused by blood accumulating under the diaphragm. Furthermore, the vital signs demonstrate a compensatory response: a narrowing pulse pressure (dropping from 4646 mm Hg to 2626 mm Hg), tachycardia, and tachypnea. The priority action is to prepare for intravascular volume replacement with isotonic fluids and to alert the healthcare provider immediately for potential surgical or vascular intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation and recent procedure history.
The client had a liver biopsy (which carries a high bleeding risk) and now has right shoulder pain, which is referred pain from phrenic nerve irritation due to subdiaphragmatic blood accumulation.
To identify potential complications specifically associated with the invasive procedure.
2
Calculate and compare the pulse pressures from the provided vital signs.
The baseline pulse pressure was 4646 mm Hg (128−82128 - 82). The current pulse pressure has significantly narrowed to 2626 mm Hg (112−86112 - 86).
A narrowing pulse pressure is a highly sensitive, early physiological indicator of hypovolemia and decreased stroke volume before systolic hypotension occurs.
3
Synthesize the vital sign trends with the clinical symptoms.
The combination of a narrowing pulse pressure, tachycardia (108108 beats/min), tachypnea (2424 breaths/min), and referred shoulder pain definitively indicates active internal hemorrhage and early hypovolemic shock.
To determine the underlying failure in physiological adaptation and recognize the shift from stability to decompensation.
4
Determine the priority nursing intervention based on the physiological findings.
The immediate priority is to initiate fluid resuscitation to restore intravascular volume and notify the provider for definitive surgical or vascular intervention.
Hypovolemic shock is a life-threatening emergency requiring prompt circulatory support and escalation of care.

Key Concept

Early recognition and management of hypovolemic shock secondary to internal hemorrhage
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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