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Soru

Zorluk: OrtaReduction of Risk Potential

An older adult client is hospitalized for the medical management of a bleeding gastric ulcer. The client is receiving a continuous intravenous infusion of normal saline. During morning rounds, the practical nurse assesses a heart rate of 118 beats per minute, a blood pressure of 92/58 mm Hg, and notes that the client appears pale and reports feeling dizzy. Which action should the practical nurse take first?

  1. A
    Increase the rate of the continuous normal saline infusion to help restore the client's intravascular volume.
  2. B
    Record the vital signs in the client's medical record and instruct the client to change positions slowly.
  3. Place the client in a supine position and immediately report the assessment findings to the supervising registered nurse.Cevap
  4. D
    Administer the client's scheduled daily dose of oral metoprolol to manage the elevated heart rate.

Cevap

The correct action is to position the client supine to promote blood flow to the brain and immediately notify the registered nurse of the significant vital sign changes.
The correct answer addresses the immediate threat to circulation (hypovolemia from bleeding) by placing the client in a supine position to enhance venous return and cerebral perfusion, while correctly acting within the practical nurse scope by immediately notifying the registered nurse of the client's deterioration.

Adım Adım Çözüm

1
Analyze the clinical data.
The client has a history of a bleeding ulcer and now presents with tachycardia (118 bpm), hypotension (92/58 mm Hg), pallor, and dizziness.
Recognizing abnormal vital signs is the essential first step in clinical judgment.
2
Interpret the meaning of the findings.
These findings are classic early signs of hypovolemic shock caused by internal bleeding.
The body compensates for fluid loss by increasing the heart rate to maintain cardiac output and perfuse vital organs.
3
Determine the priority nursing intervention within the practical nurse scope of practice.
The most appropriate action is to protect the client's safety (supine position) and immediately escalate the critical findings to the registered nurse for further medical intervention.
Practical nurses must recognize complications and communicate urgent changes to the healthcare team while staying within their designated scope of practice.

Anahtar Kavram

Early Recognition and Escalation of Hypovolemic Shock
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Konular

Reduction of Risk Potential

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