174k views
0 votes
A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The clients' initial vital signs were heart rate 80/min, blood pressure 130/70mm Hg, respiratory rate 16/min, and temperature 36 C (96.8F). Which of the following vital changes should alert the nurse that the client might be hemorrhaging?

a. Heart rate 92/min.

b. Blood pressure 118/62 mm Hg.

c. Respiratory rate 20/min.

d. Temperature 37.2 C (99 F).

User Bitnine
by
8.5k points

1 Answer

2 votes

Final answer:

The choice that should alert the nurse to possible hemorrhage is b. Blood pressure 118/62 mm Hg, as the combination of an increased heart rate and decreased blood pressure is indicative of potential hemorrhaging.

Step-by-step explanation:

The student's question is concerned with assessing which vital sign changes should alert a PACU nurse that a client might be hemorrhaging following a right nephrectomy. When considering suspected hemorrhage, critical vital sign changes to look for are an increased heart rate and decreased blood pressure, which are indicative of compensatory mechanisms trying to maintain adequate circulation despite blood loss. The signs of circulatory shock, such as tachycardia and hypotension, could develop if the hemorrhage is severe and not corrected.

Given the initial vital signs (heart rate 80/min, blood pressure 130/70 mmHg, respiratory rate 16/min, and temperature 36 C), the choice that should most alert the nurse to the possibility of hemorrhage would be b. Blood pressure 118/62 mm Hg. While the heart rate increase to 92/min is noteworthy, it is the combination with the decrease in blood pressure that indicates a more significant volume loss requiring attention and possible intervention.

User Cogman
by
8.7k points