Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

A practical nurse is assisting with the monitoring of a client who recently underwent a bedside thoracentesis to remove pleural fluid. Which of the following post-procedure assessment findings require immediate escalation to the registered nurse? (Select all that apply)

  1. A
    The client's post-procedure hemoglobin is 14.514.5 g/dL and hematocrit is 43%43\%.
  2. The client exhibits asymmetrical chest wall expansion during inspiration.Cevap
  3. The client's resting heart rate increases from 8282 to 124124 beats per minute with a blood pressure of 88/5688/56 mmHg.Cevap
  4. D
    A pulse oximetry reading of 96%96\% on 22 liters of oxygen via nasal cannula.
  5. The client reports sudden, severe chest pain accompanied by new-onset tachypnea.Cevap
  6. F
    The client reports mild tenderness at the needle insertion site, rated as a 22 on a 00 to 1010 pain scale.

Cevap

The findings that require immediate escalation are asymmetrical chest wall expansion, a significantly increased heart rate combined with hypotension, and sudden severe chest pain with new-onset tachypnea.
Following a thoracentesis, there is a risk of severe complications such as pneumothorax, hemothorax, or shock. Asymmetrical chest wall expansion, sudden severe chest pain, and new-onset tachypnea are classic clinical indicators of a pneumothorax (air entering the pleural space). A significant increase in heart rate combined with hypotension indicates potential hypovolemia, hemorrhage, or tension pneumothorax. These findings represent immediate threats to the client's airway, breathing, or circulation and require immediate escalation to the registered nurse or healthcare provider to initiate emergency interventions.

Adım Adım Çözüm

1
Analyze the clinical scenario and the recent procedure.
The client recently underwent a bedside thoracentesis, which carries inherent risks such as pneumothorax, hemothorax, and fluid shifts.
Understanding the risks of the procedure guides the nurse in what complications to monitor for.
2
Evaluate each assessment finding against normal post-procedure parameters.
Identify which findings represent expected outcomes versus life-threatening emergencies.
Expected findings (normal labs, stable SpO2, mild local pain) require routine monitoring, whereas abnormal findings indicate severe complications.
3
Select the findings that mandate immediate escalation to the registered nurse.
Asymmetrical chest expansion, tachycardia with hypotension, and sudden severe chest pain with tachypnea are selected.
These findings directly indicate airway, breathing, or circulation compromise (such as a pneumothorax or shock) requiring urgent intervention.

Anahtar Kavram

Reduction of risk potential following invasive procedures involves recognizing early clinical indicators of life-threatening complications, such as a pneumothorax or hypovolemic shock, and escalating these findings immediately.
Tahmini Süre:1m 30s
Bu soruyu puanla

Konular

Reduction of Risk Potential

Bu konudan daha fazla soru