A practical nurse (PN) is evaluating a client who is 6 hours post-operative following an abdominal hysterectomy. The client reports feeling slightly dizzy, exhausted, and having mild abdominal cramping. During the data collection, the PN notes a heart rate of 112 beats/min, a blood pressure of 98/60 mm Hg, and a fully saturated perineal pad with bright red blood. The surgical abdominal dressing remains clean and dry. Which action should the PN take first?
- Notify the registered nurse (RN) immediately about the bleeding and vital signs.Cevap
- BReassess the client's blood pressure and heart rate in 30 minutes.
- CElevate the head of the client's bed to a high-Fowler's position.
- DProvide the prescribed PRN oral analgesic for the abdominal cramping.
Cevap
The correct action is to notify the registered nurse (RN) immediately about the bleeding and vital signs.
The client is demonstrating signs of active hemorrhage and early hypovolemic shock, including tachycardia, borderline hypotension, dizziness, and heavy vaginal bleeding. In an acute deterioration involving circulation, the priority action within the practical nurse's scope of practice is to immediately notify the supervising registered nurse or healthcare provider to initiate emergency interventions.
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Anahtar Kavram
Recognizing postoperative hemorrhage and prioritizing circulation interventions