A nurse receives a client from the PACU following an appendectomy. During the initial assessment, the nurse finds a blood pressure of 88/54 mmHg, heart rate of 118 bpm, respiratory rate of 22, and the surgical dressing is saturated with dark red blood. Which action should the nurse take first?
- A.Administer the ordered PRN analgesic for incisional pain
- B.Apply pressure to the dressing and call for immediate assistance
- C.Obtain IV access and hang the ordered IV fluid bolus
- D.Elevate the foot of the bed to 30 degrees
Show answer & rationale
Correct answer
B. Apply pressure to the dressing and call for immediate assistance
Rationale
B is correct: The client shows signs of hemorrhagic shock (hypotension, tachycardia) with a saturated dressing indicating active bleeding. Applying direct pressure to the wound is the immediate intervention to slow hemorrhage while calling for assistance. This is the first step in the ABC's of hemorrhage control. A is incorrect: Analgesics are not the priority; low blood pressure and active bleeding represent an immediate life threat. C is incorrect: IV fluid resuscitation will be needed and is important, but direct pressure on the bleeding source takes priority to slow ongoing blood loss. D is incorrect: Trendelenburg or leg elevation is not recommended in hemorrhagic shock by current guidelines and does not address the active bleeding.
Key concepts