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Soru

Zorluk: ZorReduction of Risk Potential

A nursing assistant reports updated vital signs for a client who underwent a percutaneous liver biopsy 33 hours ago. The client's current blood pressure is 102/66102/66 mm Hg and heart rate is 112112 beats/min, compared to a pre-procedure baseline of 130/82130/82 mm Hg and 7878 beats/min. The client reports new, mild right shoulder pain. A review of the morning laboratory data shows a platelet count of 82,000/mm382,000/\text{mm}^3. Which action should the practical nurse take first?

  1. Examine the right upper quadrant dressing for saturation and gently palpate the abdomen for rigidity.Cevap
  2. B
    Document the vital signs in the electronic health record and plan to reassess hemodynamics in one hour.
  3. C
    Administer the prescribed as-needed oral analgesic to relieve the reported right shoulder pain.
  4. D
    Note the platelet count in the medical record as an expected baseline finding for a client with cirrhosis.

Cevap

The correct action is to examine the right upper quadrant dressing for saturation and gently palpate the abdomen for rigidity.
The correct answer involves inspecting the biopsy site and abdomen. The client's trend of falling blood pressure and rising heart rate, combined with a low platelet count and right shoulder pain (referred pain from diaphragmatic irritation), strongly suggests internal hemorrhage following the liver biopsy. Within the practical nurse scope of practice, the immediate priority is to gather focused, direct assessment data regarding the potential complication before urgently notifying the registered nurse.

Adım Adım Çözüm

1
Analyze the client's vital sign trends and presenting symptoms.
The client has a narrowing pulse pressure, hypotension, and tachycardia compared to baseline, alongside new right shoulder pain.
These are classic indicators of early hypovolemic shock and diaphragmatic irritation, strongly pointing to internal bleeding.
2
Correlate the clinical presentation with the morning laboratory results and recent procedure.
The client underwent a biopsy of a highly vascular organ (the liver) and has thrombocytopenia (low platelets).
A low platelet count significantly increases the risk of severe post-procedural hemorrhage, making the vital sign changes highly alarming.
3
Determine the priority nursing action within the practical nurse scope of practice.
The practical nurse must immediately perform a focused physical assessment of the surgical site and abdomen.
Gathering specific, direct clinical data about the potential bleeding site is required before urgently escalating the critical situation to the registered nurse.

Anahtar Kavram

Recognizing and prioritizing early signs of hemorrhagic shock and complications following invasive procedures.
Tahmini Süre:1m 30s
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Konular

Reduction of Risk Potential

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