Following an open partial gastrectomy, a client is transferred to the medical-surgical unit. hours later, the client exhibits new-onset restlessness. The client's initial vital signs were blood pressure mmHg and heart rate bpm. Current vital signs show a blood pressure of mmHg, heart rate of bpm, and respiratory rate of breaths/min. A recent laboratory report indicates a hemoglobin level of g/dL ( g/L), which has dropped from a preoperative baseline of g/dL ( g/L). Which actions are appropriate for the practical nurse to take in this situation? Select all that apply.
- Immediately notify the registered nurse about the clinical changes.Cevap
- Inspect the abdominal surgical dressing and drains for excessive sanguineous drainage.Cevap
- Confirm the patency of the client's peripheral intravenous catheter.Cevap
- DAdminister the prescribed intravenous push (IVP) analgesic to alleviate the client's restlessness.
- EDocument the findings as expected postoperative variations and reassess vital signs during the next scheduled round.
- FDefer reporting the hemoglobin result until the healthcare provider's rounds, as the value remains above the typical transfusion threshold.
Cevap
The practical nurse should immediately notify the registered nurse about the clinical changes, inspect the abdominal surgical dressing and drains for excessive sanguineous drainage, and confirm the patency of the client's peripheral intravenous catheter.
The client is demonstrating classic early signs of hypovolemic shock (tachycardia, mild hypotension, tachypnea, and restlessness) likely due to postoperative hemorrhage, supported by a significant drop in hemoglobin. The practical nurse must immediately notify the registered nurse, visually inspect the surgical site for external bleeding, and ensure intravenous access is patent for potential fluid resuscitation or blood product administration.
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Anahtar Kavram
Early Recognition and Escalation of Postoperative Hypovolemic Shock