A client with a traumatic brain injury demonstrates decorticate posturing.
Which change indicates worsening neurologic status?

This scenario involves recognizing early signs of hypovolemic shock following surgery. Knowledge of compensatory mechanisms, such as tachycardia and peripheral vasoconstriction, is essential to identify the most sensitive indicators of deteriorating hemodynamic status after significant intraoperative blood loss.

Choice A rationale

Tachycardia is typically the earliest compensatory sign of shock. As stroke volume falls due to blood loss, the heart rate increases to maintain cardiac output. A jump from 88 to 118 bpm is a significant clinical alarm.

Choice B rationale

While 20 mL/hr is below the normal 30 mL/hr threshold, decreased urine output often occurs after heart rate changes. It reflects reduced renal perfusion as a later compensatory response to sustain blood flow to the brain.

Choice C rationale

Incisional pain is an expected postoperative finding and does not indicate hypovolemic shock. Pain may actually cause a sympathetic surge that increases heart rate, but it is not a diagnostic marker for circulatory collapse in this context.

Choice D rationale

Capillary refill less than 2 seconds is a normal finding indicating adequate peripheral perfusion. In hypovolemic shock, skin becomes cool and pale, and capillary refill would typically be prolonged beyond 2 to 3 seconds.

Delegation requires understanding the scope of practice for unlicensed assistive personnel versus licensed nurses. Tasks involving clinical judgment, titration of medications, or invasive monitoring must be reserved for the registered nurse, while routine, non-invasive tasks can be safely delegated.

Choice A rationale

Central venous pressure monitoring involves an invasive line and requires clinical interpretation of waveforms and readings. This task is beyond the scope of unlicensed personnel and must be performed by a nurse to ensure accuracy and safety.

Choice B rationale

Oral care is a routine hygiene task that falls within the scope of practice for unlicensed assistive personnel. Regular oral care is essential for preventing ventilator-associated pneumonia and maintaining mucosal integrity in critically ill septic patients.

Choice C rationale

While some glucose monitoring can be delegated, hourly measurements in a septic patient typically require clinical titration of insulin or close monitoring of metabolic instability. Agency policies often restrict high-frequency or critical-care monitoring to licensed staff.

Choice D rationale

Titration of vasoactive medications like norepinephrine requires advanced clinical judgment and assessment of hemodynamics. This is a complex nursing intervention that can never be delegated to unlicensed staff due to the high risk of hemodynamic instability.

Choice E rationale

Assessing vital signs in a hemodynamically unstable septic patient involves clinical evaluation. Furthermore, measuring urine output via a catheter in an intensive care setting is often combined with assessing renal perfusion, requiring professional nursing oversight.

Choice F rationale

Measuring and documenting intake and output is a standard technical task delegated to unlicensed personnel. While the nurse must interpret the clinical significance of the balance, the manual collection and recording of data are appropriate delegated duties.