# A nurse is caring for a 60-year-old postoperative patient who underwent hip replacement surgery 4 hours ago and suddenly develops signs of hypovolemic shock with blood pressure 80/50 mmHg, heart rate 120 bpm, weak pulse, cool clammy skin, and decreased urine output. Which nursing intervention should be the nurse's FIRST priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542732 > language: ko > subject: Fundamentals ## 문제 A nurse is caring for a 60-year-old postoperative patient who underwent hip replacement surgery 4 hours ago and suddenly develops signs of hypovolemic shock with blood pressure 80/50 mmHg, heart rate 120 bpm, weak pulse, cool clammy skin, and decreased urine output. Which nursing intervention should be the nurse's FIRST priority? ## 보기 1. Establish large-bore IV access and initiate fluid resuscitation **✔ 정답** 2. Administer prescribed pain medication to reduce patient discomfort 3. Place the patient in Trendelenburg position to improve venous return 4. Obtain blood samples for laboratory analysis including CBC and electrolytes **정답: 1** ## 해설 In hypovolemic shock, the priority is to restore circulating volume via large-bore IV access and fluid resuscitation to prevent organ failure. Other options like pain medication or Trendelenburg position are secondary or not evidence-based. ## 심화 해설 Clinical Priority Setting in Acute Postoperative Hypovolemic Shock The patient is exhibiting classic signs of decompensated hypovolemic shock, a life-threatening condition resulting from a critical loss of intravascular volume. In the context of a recent hip replacement, this is likely due to significant blood loss into the surgical site. The presented vital signs—blood pressure 80/50 mmHg and heart rate 120 bpm—indicate that compensatory mechanisms are failing, leading to impaired oxygen delivery to vital organs [1]. The nurse's immediate priority must address the root cause of this hemodynamic instability: the profound lack of circulating volume. The first and most critical intervention is to establish large-bore IV access and initiate fluid resuscitation. This action directly aligns with the foundational principle of shock management, which is to restore intravascular volume and improve tissue perfusion. The evidence synthesis by Wang et al. emphasizes that prompt fluid resuscitation is critical, with nurses playing a central role in early recognition and timely intervention [1]. A large-bore catheter (e.g., 18-gauge or larger) is essential to facilitate the rapid infusion of isotonic crystalloids or blood products, as dictated by the Poiseuille's law, where flow rate is directly proportional to the fourth power of the catheter's radius. Delaying this step to perform other tasks prolongs the state of cellular hypoxia and increases the risk of progression to irreversible shock and multi-organ failure. The other options are not the first priority. Administering pain medication (Option 2) is contraindicated in this scenario. Opioids and other analgesics can cause vasodilation and further depress the already compromised cardiovascular system, potentially precipitating a complete cardiovascular collapse. Placing the patient in the Trendelenburg position (Option 3) is an outdated and unsupported practice for hypovolemic shock. This position does not effectively improve venous return and can instead increase intracranial pressure, impair pulmonary gas exchange by pushing abdominal contents against the diaphragm, and increase cardiac afterload. Obtaining blood samples for laboratory analysis (Option 4) is an important diagnostic step but is secondary to the life-saving intervention of fluid resuscitation. While a complete blood count (CBC) and electrolytes will guide ongoing therapy, the immediate threat to the patient's life is the lack of perfusion, which must be corrected without delay. The case review by Eraky et al. reinforces that management must be guided by a thorough understanding of physiology, where addressing the hemodynamic derangement takes precedence over rigid protocol-driven diagnostics .References (research sources) - [1]Best evidence for fluid resuscitation nursing in hypovolemic shock patients in emergency care based on GRADE system.Research articleWang Y, Lin J, Lin Y. (2026) · DOI: 10.2478/abm-2026-0009 ## 임상 시나리오 Clinical Practice Guide: Postoperative Hypovolemic Shock Immediate Nursing Actions - Recognize decompensated shock: hypotension, tachycardia, weak pulse, cool/clammy skin, oliguria. - Activate rapid response or surgical emergency team immediately. - Establish two large-bore (18-gauge or larger) IV lines in large proximal veins (e.g., antecubital fossa). - Initiate rapid fluid resuscitation with warmed isotonic crystalloids (e.g., 0.9% normal saline, lactated Ringer's) using a pressure bag or rapid infuser. - Administer high-flow oxygen via non-rebreather mask to maximize oxygen delivery. Ongoing Assessment and Monitoring - Monitor vital signs every 5-15 minutes: blood pressure, heart rate, respiratory rate, oxygen saturation. - Assess for ongoing bleeding: inspect surgical site, drain output, and measure abdominal girth if internal bleeding is suspected. - Insert an indwelling urinary catheter to accurately monitor urine output (goal: greater than 0.5 mL/kg/hr). - Observe for signs of fluid overload (crackles, dyspnea, JVD) once volume is being restored. - Prepare for blood product transfusion (packed red blood cells, fresh frozen plasma, platelets) as ordered based on lab results and massive transfusion protocol. Evidence-Based Considerations - Trendelenburg position is not recommended as a first-line intervention; it may impair respiratory mechanics and does not significantly improve cardiac output. - Pain management with opioids should be deferred until hemodynamic stability is achieved due to the risk of vasodilation and respiratory depression. - Laboratory studies (CBC, coagulation panel, electrolytes, type and crossmatch) should be drawn simultaneously with IV access but must not delay fluid resuscitation. - If the patient does not respond to initial crystalloid bolus (persistent hypotension), consider ongoing surgical bleeding as the primary cause and prepare for possible return to the operating room. ## 핵심 개념 - **Hypovolemic shock** — A life-threatening condition caused by a critical loss of intravascular volume leading to inadequate tissue perfusion and cellular hypoxia. - **Poiseuille's law** — A physical principle stating that flow rate through a tube is directly proportional to the fourth power of the radius, emphasizing the need for a large-bore IV for rapid fluid infusion. - **Isotonic crystalloids** — Intravenous fluids such as 0.9% normal saline or lactated Ringer's solution that have a similar osmotic pressure to blood plasma and are used for initial volume expansion. ## 같은 주제 문제 - [A nurse is caring for a postoperative patient who underwent major abdominal surgery 48 hou…](https://mymerci.kr/pages/nclex_q.php?qn_id=542729) - [A nurse is assessing a patient who underwent exploratory laparotomy for bowel obstruction …](https://mymerci.kr/pages/nclex_q.php?qn_id=542730) - [A nurse is caring for a 65-year-old postoperative patient who underwent major abdominal su…](https://mymerci.kr/pages/nclex_q.php?qn_id=542731) - [A nurse is caring for a 70-year-old postoperative patient with a history of COPD who under…](https://mymerci.kr/pages/nclex_q.php?qn_id=542733) - [A nurse is caring for a 30-year-old postoperative patient who underwent emergency appendec…](https://mymerci.kr/pages/nclex_q.php?qn_id=542734) - [A nurse is caring for a 60-year-old postoperative patient who underwent laparoscopic chole…](https://mymerci.kr/pages/nclex_q.php?qn_id=542735) - [A nurse is caring for a postoperative patient who suddenly becomes restless, with decrease…](https://mymerci.kr/pages/nclex_q.php?qn_id=542736) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._