A practical nurse (PN) is prioritizing care for a client who is 6 hours postoperative following a partial bowel resection. The PN reviews the client's current assessment data and laboratory results. Which of the following findings indicate a potential complication requiring immediate escalation to the registered nurse (RN)? Select all that apply.
- Heart rate of 118 beats/min and blood pressure of 90/58 mm HgCevap
- Serum potassium level of 2.8 mEq/L (2.8 mmol/L)Cevap
- Total urine output of 45 mL over the past 3 hoursCevap
- DAbsent bowel sounds in all four abdominal quadrants
- ETemperature of 99.2°F (37.3°C) and respiratory rate of 18 breaths/min
- FIncisional pain rated as 5 on a 0 to 10 scale
Cevap
The findings requiring immediate escalation are the elevated heart rate with hypotension, the critically low serum potassium level, and the decreased total urine output over the past 3 hours.
The correct findings requiring immediate escalation include the elevated heart rate combined with hypotension, the critically low potassium level, and the oliguria. Tachycardia and hypotension are early systemic indicators of hypovolemic shock or internal hemorrhage. A serum potassium of 2.8 mEq/L is critically low and places the client at immediate risk for life-threatening cardiac dysrhythmias. Furthermore, a total urine output of 45 mL over 3 hours equates to 15 mL/hr, which is well below the minimum expected 30 mL/hr threshold and indicates significantly compromised renal perfusion or fluid volume deficit.
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Anahtar Kavram
Recognizing and prioritizing early signs of postoperative complications (shock, hypokalemia, and oliguria) over expected physiological findings.