Question

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 110/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36 C (98.7 F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging?

Options:
a) Heart rate increased to 120/min
b) Blood pressure decreased to 120/60 mm Hg
c) Respiratory rate increased to 20/min
d) Temperature decreased to 35.5 C (95.9 F)

Answer 1

The vital signs that should alert the nurse of possible hemorrhage are a rapid increase in heart rate and a decrease in blood pressure, indicating hypovolemic shock due to blood loss.

Step-by-step explanation:

The student is asked which vital sign change should alert the PACU nurse that the client who had a right nephrectomy might be hemorrhaging. The most indicative signs of hemorrhage in a patient are a rapid increase in heart rate and a decrease in blood pressure. Specifically, option (a) heart rate increased to 120/min and option (b) blood pressure decreased to 120/60 mm Hg, when considered together, strongly suggest the possibility of hemorrhage. This is because the body will respond to a loss of blood volume by increasing the heart rate to maintain cardiac output and tissue perfusion, but as blood loss continues, blood pressure will eventually drop. This response is a hallmark of hypovolemic shock caused by hemorrhage, where the heart tries to compensate for reduced blood volume by pumping more quickly (tachycardia), but peripheral resistance lowers the blood pressure.