A practical nurse (PN) is reviewing assessment data for a group of assigned clients. Which… — NCLEX-PN

A practical nurse (PN) is reviewing assessment data for a group of assigned clients. Which of the following findings indicate a developing complication and require the PN to immediately escalate care to the registered nurse (RN)? Select all that apply.

A client 4 hours post-thyroidectomy who is observed frequently swallowing and clearing their throat.Answer
A client receiving a continuous enteral tube feeding who suddenly begins coughing forcefully and expelling frothy sputum.Answer
C
A client 2 days post-appendectomy who has an oral temperature of $99.4^\circ\text{F}$ ( $37.4^\circ\text{C}$ ) and reports incisional pain as 3 on a 0-to-10 scale.
A client receiving intravenous (IV) furosemide whose morning serum potassium level is $2.8\text{ mEq/L}$ ( $2.8\text{ mmol/L}$ ).Answer
E
A client receiving subcutaneous enoxaparin who has a morning platelet count of $185,000/\text{mm}^3$ ( $185 \times 10^9/\text{L}$ ).
A client 2 hours post-cardiac catheterization whose heart rate increases from 78 to 114 beats/minute and blood pressure drops from 122/76 to 96/60 mm Hg.Answer

Answer

The findings requiring immediate escalation are: the client frequently swallowing post-thyroidectomy, the client forcefully coughing during enteral feeding, the critically low potassium level of

2.8\text{ mEq/L}

, and the client developing tachycardia with hypotension post-cardiac catheterization.

Complications that compromise Airway, Breathing, and Circulation (ABCs) or pose an immediate risk to life require immediate escalation. Frequent swallowing post-thyroidectomy is a classic sign of hemorrhage causing hematoma formation and airway compression. Forceful coughing with frothy sputum in a client with an enteral feeding tube strongly suggests displacement into the airway and aspiration. A serum potassium level of

2.8\text{ mEq/L}

is critically low (normal

3.5-5.0\text{ mEq/L}

) and can cause fatal cardiac arrhythmias, especially when exacerbated by loop diuretics like furosemide. Finally, a sudden shift toward tachycardia and hypotension following an invasive arterial procedure like a cardiac catheterization is a primary indicator of hemorrhagic shock.

Step-by-Step Solution

Analyze airway and breathing risks in the provided scenarios.

Frequent swallowing post-thyroidectomy indicates internal bleeding pooling in the neck. Coughing with frothy sputum during enteral feeding indicates aspiration. Both require immediate escalation.

Airway compromise is an acute, life-threatening emergency (prioritization of ABCs).

Evaluate laboratory values against normal reference ranges.

A potassium level of

2.8\text{ mEq/L}

is critically low and requires escalation. A platelet count of

185,000/\text{mm}^3

is completely normal.

Failure to report critical lab values increases risk potential, while escalating normal values wastes clinical resources.

Assess vital signs to distinguish expected postoperative trajectories from hemodynamic instability.

Tachycardia and a dropping blood pressure post-catheterization suggest hemorrhagic shock (escalate). A temperature of

99.4^\circ\text{F}

on postoperative day 2 is a normal inflammatory response (do not escalate).

Accurate interpretation of vital sign trends is essential for early recognition of complications.

Select all findings that represent acute, life-threatening complications outside the expected recovery trajectory.

The correct selections relate to the thyroidectomy, enteral feeding, potassium level, and cardiac catheterization.

These four scenarios demand immediate RN or provider intervention to mitigate severe risk.

Key Concept

Early Recognition of Post-Procedure Complications and Critical Abnormalities

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