Question

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80, bp 130/70, rr 16, and temp 96.8 F. Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging?

A. Heart rate 120

B. Blood pressure 90/50

C. Respiratory rate 24

D. Temperature 98.6

Answer 1

The vital sign change that should alert the nurse that the client might be hemorrhaging is a blood pressure of 90/50.

Step-by-step explanation:

The vital sign change that should alert the nurse that the client might be hemorrhaging is a blood pressure of 90/50. A blood pressure reading of 90/50 is significantly lower than the normal range of 90/60 to 120/80 mm Hg, indicating a decrease in blood volume and potential hemorrhage.

Hemorrhaging is the loss of blood from the body, and it can lead to various complications if not addressed promptly. A decrease in blood pressure can be a sign of hemorrhaging because it indicates a decrease in the force exerted by the blood against the artery walls.

The nurse should assess the client further for other signs of hemorrhaging such as tachycardia (rapid heart rate), pale skin, cool and clammy extremities, and a decrease in urine output.