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Zorluk: KolayReduction of Risk Potential

A practical nurse is providing care for a client who is recovering on the medical-surgical unit two days after abdominal surgery. As part of minimizing risk potential, the nurse monitors clinical data and ongoing care activities. Which of the following findings or observations require immediate escalation or corrective intervention? (Select all that apply.)

  1. A resting heart rate of 118118 beats per minute accompanied by new-onset restlessnessCevap
  2. A morning laboratory report showing a serum white blood cell (WBC) count of 17,500/mm317,500/mm^3Cevap
  3. C
    A serum potassium level of 4.24.2 mEq/L reported in the routine morning laboratory results
  4. D
    A blood pressure measurement of 118/78118/78 mm Hg and a respiratory rate of 1414 breaths per minute
  5. E
    A colleague scanning the client's identification bracelet and confirming two unique identifiers prior to dispensing a pain medication

Cevap

The findings that require immediate escalation are the resting heart rate of 118 beats per minute with restlessness, and the elevated white blood cell count of 17,500/mm��.
A heart rate of 118 beats per minute combined with new-onset restlessness is a classic early indicator of hypovolemic shock or internal bleeding. Furthermore, a white blood cell count of 17,500/mm³ strongly suggests a postoperative infection. Both of these findings represent significant, acute risks to the client and require immediate escalation to the registered nurse or healthcare provider.

Adım Adım Çözüm

1
Analyze the vital signs and clinical presentation for early signs of postoperative complications.
A heart rate of 118 beats per minute combined with restlessness is abnormal and may indicate early hypovolemia or hemorrhage.
Tachycardia and mental status changes are critical early warning signs that require the registered nurse's immediate assessment before blood pressure drops.
2
Evaluate the laboratory values against normal reference ranges.
The WBC count of 17,500/mm³ is significantly elevated above the normal range of 5,000 to 10,000/mm³.
Leukocytosis indicates a potential postoperative infection requiring prompt medical intervention.
3
Review the remaining clinical observations for appropriateness.
The potassium level, blood pressure, respiratory rate, and medication administration process are all within normal, safe limits.
Identifying expected, safe outcomes ensures that interventions are only directed toward true risks, preventing unnecessary escalation.

Anahtar Kavram

Recognizing early clinical indicators of postoperative complications, including shock and infection, to ensure prompt escalation and reduce client risk.
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Konular

Reduction of Risk Potential

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