Fundamentals Question #32

Question

A client recovering from surgery becomes restless and is cold and clammy. Vital signs are: pulse 125 bpm; respirations 26/min; and BP 80/55 mm Hg. Which intervention should the nurse complete first?

Answers

  1. Call the charge nurse
    • Rationale:

      This answer is not correct because hemorrhage or bleeding symptoms include restlessness, skin cold and clammy, tachycardia, tachypnea, and hypotension. The first action the nurse should do is notify the surgeon immediately, not the charge nurse. The nurse can not give orders for life-saving intervention. Unless the charge nurse can make the call to the surgeon while the nurse is assessing and caring for the client, the nurse should contact the surgeon first.

  2. Place the bed in reverse Trendelenburg position
    • Rationale:

      This answer is not correct because Trendelenburg, not reverse Trendelenburg is most often used to help hypotension caused by hemorrhage. The most appropriate priority action listed is to contact the surgeon because the client is exhibiting hemorrhage symptoms. Immediately after surgery is a high risk time because the body has been recently cut and manipulated while performing surgery. Clinical manifestations of hemorrhage or bleeding include restlessness, skin cold and clammy, tachycardia, tachypnea, and hypotension.

  3. Notify the surgeon immediately
    • Rationale:

      This answer is correct because the surgeon should be notified immediately since not only do orders need to be given immediately, but the client likely needs to return to surgery to stop the hemorrhaging area. Generally, IV fluids will be given, vasopressors, blood products, etc. as the client is sent to surgery for a repair to stop the hemorrhaging. Immediately after surgery is a high risk time because the body has been recently cut and manipulated while performing surgery. Clinical manifestations of hemorrhage or bleeding include restlessness, skin cold and clammy, tachycardia, tachypnea, and hypotension.

  4. Recheck blood pressure with a manual sphygmomanometer
    • Rationale:

      This answer is not correct because the client is exhibiting other clinical manifestations that reflect hemorrhage, besides hypotension, such as restlessness, skin cold and clammy, tachycardia, and tachypnea, Therefore, the nurse’s first action is to contact the surgeon. Orders need to be given to help stabilize the client and the surgeon likely will need to take the client back to surgery.

Overview

The symptoms of hemorrhaging in a client recovering from surgery include restlessness, skin cold and clammy, tachycardia, tachypnea, and hypotension. The surgeon should be notified immediately.

Explanation

Learning Outcomes

Hemorrhage or bleeding describes blood loss, which can be internal or external. Immediately after surgery is a high risk time because the body has been recently cut and manipulated while performing surgery. Clinical manifestations of hemorrhage or bleeding include restlessness, skin cold and clammy, tachycardia, tachypnea, and hypotension. The surgeon should be notified immediately because not only do orders need to be given immediately but the client likely needs to return to surgery to stop the hemorrhaging area. If bleeding is occuring internally, the area of bleeding may feel hard or distended. External bleeding is more obvious with the bleeding soaking bandages, bedsheets, etc. Generally, IV fluids will be given, vasopressors, blood products, etc. as the client is sent to surgery for a repair to stop the hemorrhaging.

Test Taking Tip

Remember to look at the whole picture when considering what is going on with a client. Key words, such as “recovering from surgery” with symptoms that indicate hemorrhage (restlessness, skin cold and clammy, tachycardia, tachypnea, and hypotension) is a huge cue that hemorrhage symptoms are occuring.

Video Rationale