it is Friday the 13th and a full moon. You are an LPN that normally works on a medical-surgical unit, but your unit is overstaffed, and the emergency department is short staffed. The nursing supervisor asks for a volunteer to go down to be an extra pair of hands. You volunteer as tribute. When you get to the ER, you are asked to do vitals on a client in the trauma room. The client is a 24-year-old male who was stabbed multiple times to the abdomen.
The wounds appear superficial, and the client has been stable thus far. He will be going to CAT scan as soon as they can fit him in. You approach the client, who appears slightly pale with cool, clammy but is alert and talkative. The vital signs are:
97.3 (PO) P= 115 BP= 95/54 Resp rate= 24 Pain= 6/10. You notice the client voided 100 mL tea-colored urine in his urinal.
One hour later, the client becomes unconscious. His pulse is now 144, and blood pressure is 70/50. The client is taken to the OR and has a nephrectomy for a very damaged and bleeding right kidney.
Answer the following questions:
- What were the clues in the data collection that should have alerted you and the staff that there might be a problem? (5-10 sentences)
- Why is the urine “tea-colored?” (one sentence)
- What are some other interventions that could have been done? (2-5 sentences)
- Was the LPN in this scenario working within the scope of practice for an LPN? Why or why not? (5-10 sentences)
- How did the environment of care (busy ER) contribute to the client’s deterioration? (5-10 sentences)