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Zorluk: ZorPhysiological Adaptation

Following a scheduled bowel resection, a 76-year-old client is recovering on the medical-surgical unit. Five hours post-procedure, the client becomes increasingly restless and reports severe, diffuse abdominal pain. The practical nurse (PN) obtains the following vital signs: heart rate 115 beats per minute, blood pressure 92/64 mm Hg, and respiratory rate 24 breaths per minute. Which actions should the PN prioritize? Select all that apply.

  1. Examine the surgical dressing and the linens underneath the client for signs of active bleedingCevap
  2. Promptly escalate the vital sign changes and the client's restlessness to the registered nurseCevap
  3. Confirm the patency of the client's peripheral intravenous accessCevap
  4. D
    Administer the prescribed as-needed opioid analgesic to alleviate the severe abdominal pain
  5. E
    Record the clinical data as anticipated postoperative recovery signs and continue routine monitoring
  6. F
    Attribute the client's restlessness to age-related cognitive changes following anesthesia exposure

Cevap

The correct actions are to examine the surgical site for active bleeding, escalate the critical findings to the registered nurse, and confirm the patency of the intravenous access.
The client is demonstrating early signs of hypovolemic shock (tachycardia, hypotension, tachypnea, and restlessness) following major surgery. The practical nurse must prioritize actions that address this life-threatening circulatory compromise. Examining the surgical site helps identify the source of bleeding. Confirming intravenous access prepares the client for necessary fluid or blood resuscitation. Escalating the situation to the registered nurse is mandatory for further medical intervention and provider notification.

Adım Adım Çözüm

1
Analyze the client's vital signs and clinical presentation.
The client is exhibiting tachycardia (115 bpm), borderline hypotension (92/64 mm Hg), tachypnea (24 breaths/min), and acute restlessness in the context of recent major abdominal surgery.
Identifying abnormal findings is the first step in clinical judgment.
2
Interpret the meaning of these combined physiological findings.
These findings are classic early indicators of hypovolemic shock, likely due to internal or external hemorrhage, rather than routine postoperative pain.
Connecting data points helps the nurse recognize life-threatening physiological adaptations.
3
Determine the priority interventions based on the airway, breathing, circulation (ABC) framework.
The nurse must prioritize interventions that address circulation (assessing for bleeding, ensuring IV access for fluid resuscitation) and escalate the critical situation to the RN.
Interventions must focus on resolving the most immediate threat to the client's life before addressing secondary issues like pain.

Anahtar Kavram

Early Recognition and Prioritization of Hypovolemic Shock
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Konular

Physiological Adaptation

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