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Question

Difficulty: MediumReduction of Risk Potential

A nurse is evaluating the clinical data and current status of several assigned clients. Which of the following situations indicate a significant risk for physiological complications and require immediate nursing intervention? Select all that apply.

  1. A client receiving continuous enteral nutrition who is placed in a supine position during a bed bath.Answer
  2. A client recovering from a cardiac catheterization via the right femoral artery who has the head of the bed elevated to 60 degrees.Answer
  3. C
    A client with severe chronic obstructive pulmonary disease (COPD) whose arterial blood gas reveals a pH of 7.35, PaCO2 of 58 mm Hg, and HCO3- of 32 mEq/L.
  4. D
    A client who is 2 hours post-lumbar puncture, positioned flat in bed, and reporting a mild headache.
  5. A client receiving a continuous intravenous heparin infusion whose platelet count has decreased from 260,000/mm³ to 115,000/mm³ over 48 hours.Answer
  6. F
    A client who is 12 hours post-operative from a laparoscopic cholecystectomy reporting referred right shoulder pain.

Answer

The situations requiring immediate intervention are the client receiving enteral nutrition while supine, the client with a femoral access site and the head of the bed elevated to 60 degrees, and the client receiving heparin with a rapidly decreasing platelet count.
The situations requiring immediate intervention involve direct risks for severe physiological complications. A supine position during continuous enteral feeding creates a high risk for pulmonary aspiration. Elevating the head of the bed to 60 degrees after a femoral arterial puncture causes hip flexion, which can dislodge the clot and cause severe hemorrhage. A platelet drop of more than 50% during heparin therapy indicates highly dangerous heparin-induced thrombocytopenia (HIT), requiring the immediate cessation of the medication.

Step-by-Step Solution

1
Analyze the client receiving enteral feeding in a supine position.
Recognize that the supine position eliminates gravity's assistance in keeping gastric contents down.
Identifying the severe risk of aspiration pneumonia necessitates immediate intervention to elevate the head of the bed or pause the feeding.
2
Evaluate the client recovering from a femoral cardiac catheterization with the head of the bed at 60 degrees.
Identify that significant hip flexion places excessive pressure and tension on the femoral arterial puncture site.
Preventing life-threatening retroperitoneal bleeding or hematoma formation requires lowering the head of the bed to 30 degrees or less.
3
Assess the COPD client's ABG results.
Determine that a pH of 7.35 is on the lower end of normal, PaCO2 is elevated, and HCO3- is elevated.
Understanding that this represents fully compensated respiratory acidosis, which is an expected baseline for severe COPD, meaning no immediate intervention is needed.
4
Evaluate the client post-lumbar puncture.
Recognize that lying flat in bed is the prescribed therapeutic position after this procedure.
Maintaining this position minimizes cerebrospinal fluid leakage and reduces the severity of post-puncture headaches.
5
Analyze the platelet count trend for the client on a heparin infusion.
Note a greater than 50% drop in platelet count (from 260,000 to 115,000/mm³) within 48 hours.
Recognizing this as the primary indicator of heparin-induced thrombocytopenia (HIT) requires immediately stopping the heparin and notifying the provider.
6
Assess the post-laparoscopic cholecystectomy client with shoulder pain.
Identify that referred right shoulder pain is caused by the carbon dioxide gas used to inflate the abdomen during surgery.
Knowing this is a normal, expected postoperative finding means reassurance and early ambulation are needed, not emergency intervention.

Key Concept

Reduction of Risk Potential: Recognizing Complications and Expected Findings
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Topics

Reduction of Risk Potential

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