Question

A registered nurse (RN) has delegated care of a newly postoperative client to a licensed practical nurse (LPN). The LPN notifies the RN that the client's blood pressure and respirations are elevated from the baseline readings and that the client is complaining of pain and dyspnea. The RN takes which action next?

1) the RN need not to carry out further assessment because the LPN is very experienced and trustworthy
2) the RN requests that the LPN offer the client a opioid analgesic, which has ordered postoperatively
3) the RN places a call to the attending surgeon and reports that the client is having pain and dyspneic
4) the RN assesses the client, checks the client's surgical notes, and gathers addition data before calling the surgeon

Answer 1

An RN, after being notified by an LPN of a postoperative patient's changes in condition, should assess the patient, review surgical notes, check the patient's history, and review equipment before contacting the surgeon for further instructions.

Step-by-step explanation:

When a Licensed Practical Nurse (LPN) informs a Registered Nurse (RN) that a postoperative patient is experiencing elevated blood pressure, increased respirations, pain, and dyspnea, the RN's first action should be to perform a detailed assessment. The RN would evaluate the patient's clinical status, compare it to the baseline preoperative measurements, and consult the surgical notes for any specific instructions or expected outcomes related to the surgery. Additionally, the RN would gather more data that may be relevant to the patient's current state. This includes reviewing the patient's history, checking for postoperative complications, and ensuring there are no issues with the surgical equipment used. Surgical notes, patient's history, and equipment reviews are crucial steps to be undertaken before escalating the concern to the surgeon.

The imperative for the RN to be thorough is underscored by protocols that demand close monitoring of postoperative patients under direct supervision. The RN should also ensure that all safety measures were confirmed pre-surgery, such as verifying the patient's identity, surgical site, and confirmation of sterility. The RN's rigorous assessment will guide whether urgent intervention is required or if there's a need to contact the surgeon to manage the patient's symptoms effectively.