A practical nurse is assigned to care for a client who returned to the medical-surgical unit two hours ago following a percutaneous liver biopsy. During the current assessment, the nurse notes the client's blood pressure is 84/50 mm Hg and the heart rate is 122 beats per minute. Which action should the nurse take first?
- ADocument the vital signs in the health record and reassess in one hour.
- Immediately report these findings to the supervising registered nurse.Cevap
- CAsk the client to rate their current level of discomfort on a zero to ten scale.
- DIncrease the rate of the client's continuous intravenous fluid infusion.
Cevap
The correct action is to immediately report these findings to the supervising registered nurse, as they indicate a potential hemorrhage.
The liver is a highly vascular organ, placing the client at high risk for internal hemorrhage following a biopsy. A sudden drop in blood pressure accompanied by an increased heart rate are classic signs of hypovolemic shock. The practical nurse must immediately report these critical findings to the registered nurse so that rapid medical interventions can be initiated.
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Anahtar Kavram
Recognizing early signs of hypovolemic shock following an invasive procedure and escalating to the RN.