NCLEX-RNReduction of Risk PotentialEasy
A nurse is caring for a client 4 hours after total hip arthroplasty. On admission to the unit, vital signs were BP 128/78 mmHg and HR 82/min. Now the client's BP is 96/56 mmHg, HR 118/min, RR 22/min, and the skin is pale and diaphoretic. The surgical dressing is dry and intact. Which action should the nurse take first?
- AAdminister the PRN pain medication for anxiety-related tachycardia
- BReinforce the dressing and recheck vital signs in 1 hour
- CEncourage oral fluids to increase circulating volume
- DNotify the health care provider immediately
Show answer & explanationAnswer & explanation
Correct answer: D. Notify the health care provider immediately
Rising heart rate with falling blood pressure, pallor, and diaphoresis are classic signs of hypovolemic shock, likely from internal bleeding at the surgical site even though the outer dressing is dry. The nurse must notify the provider immediately so the client can be evaluated and treated before decompensation worsens.
Why the other options are wrong
- A. Masks vital shock symptoms without addressing the underlying hemodynamic instability.
- B. Delays recognition of a potentially life-threatening bleed; a dry dressing does not rule out internal hemorrhage.
- C. Oral fluids alone cannot correct significant blood loss and may be unsafe if surgery is needed.
Postoperative Hemorrhage/Hypovolemic Shock
Internal bleeding after surgery can occur even with a dry external dressing, presenting as tachycardia, hypotension, pallor, and diaphoresis.
- Tachycardia is an early compensatory sign of blood loss
- Hypotension is often a late sign of shock
- A dry dressing does not exclude internal hemorrhage
Memory trick: Cold, Clammy, Collapse—Call!