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Soru

Zorluk: KolayReduction of Risk Potential

The practical nurse (PN) is collecting vital signs on a client who is 4 hours postoperative following abdominal surgery. Which finding requires the PN to notify the registered nurse (RN) immediately?

  1. Blood pressure of 88/56 mm Hg and a heart rate of 118 beats per minuteCevap
  2. B
    The client reporting incisional pain of 6 on a 0 to 10 numerical scale
  3. C
    A tympanic temperature of 37.4°C (99.3°F)
  4. D
    A postoperative hemoglobin level of 13.5 g/dL (135 g/L)

Cevap

The correct answer is the finding of a blood pressure of 88/56 mm Hg and a heart rate of 118 beats per minute.
A low blood pressure (hypotension) combined with a fast heart rate (tachycardia) in a postoperative client are classic early signs of hypovolemic shock or internal hemorrhage. This indicates compromised circulation, which is a life-threatening emergency that must be immediately reported to the RN.

Adım Adım Çözüm

1
Identify the client's clinical context.
The client is 4 hours postoperative.
Surgical clients are at high risk for complications such as hemorrhage in the immediate postoperative period.
2
Analyze each assessment finding for severity and priority.
The low blood pressure and tachycardia indicate circulatory compromise.
According to the ABCs (Airway, Breathing, Circulation) framework, circulatory issues are life-threatening and take highest priority.
3
Determine the appropriate PN nursing action.
The PN must report the vital signs indicating shock to the RN.
Signs of physiological instability must be immediately escalated to the RN for further assessment and intervention.

Anahtar Kavram

Early recognition of hypovolemic shock and prioritization of circulatory compromise.
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Konular

Reduction of Risk Potential

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