Examkin

Soru

Zorluk: Çok zorReduction of Risk Potential

A practical nurse (PN) is reviewing the morning data for a 72-year-old client who is 24 hours post-operative following a right total hip arthroplasty. The client is scheduled to receive a morning dose of subcutaneous enoxaparin.

Assessment ParameterPreoperative BaselineCurrent Morning Data
Blood Pressure138/82 mm Hg104/62 mm Hg
Heart Rate76 beats/min98 beats/min
Hemoglobin13.5 g/dL10.1 g/dL

The client reports feeling dizzy when sitting on the edge of the bed and rates incisional pain as a 4 on a 0 to 10 scale. Based on these findings, which action represents the most appropriate risk reduction strategy for the PN to take?

  1. A
    Administer the scheduled enoxaparin, as the client's heart rate and blood pressure currently remain within normal adult limits.
  2. Withhold the subcutaneous enoxaparin and immediately notify the registered nurse of the client's clinical trends.Cevap
  3. C
    Document the hemoglobin result in the electronic record, because a value of 10.1 g/dL does not meet the critical threshold for a transfusion.
  4. D
    Accept a delegated assignment from the charge nurse to initiate a rapid intravenous normal saline bolus to resolve the client's dizziness.

Cevap

The most appropriate action is to withhold the subcutaneous enoxaparin and immediately notify the registered nurse of the client's clinical trends.
The client is demonstrating subtle signs of early hypovolemic shock and active bleeding, evidenced by a 3.4 g/dL drop in hemoglobin, a significant decrease in blood pressure from baseline, compensatory tachycardia, and orthostatic dizziness. Administering an anticoagulant like enoxaparin in the presence of active bleeding poses a severe, life-threatening risk. The priority for the practical nurse is to reduce risk by withholding the contraindicated medication and immediately escalating the findings to the registered nurse for intervention.

Adım Adım Çözüm

1
Analyze the vital sign trends from baseline to current.
Blood pressure has dropped significantly (narrowing pulse pressure) and heart rate has increased by 22 beats per minute.
Absolute vital signs may appear normal, but a significant deviation from baseline indicates physiological stress or compensation.
2
Evaluate the laboratory data changes.
Hemoglobin dropped by 3.4 g/dL in 24 hours.
A rapid drop in hemoglobin, even if the current value is not critically low, signifies substantial acute blood loss.
3
Interpret the clinical symptoms in context.
Dizziness upon sitting up indicates orthostatic hypotension.
Orthostatic changes strongly support a fluid volume deficit, correlating with the suspected blood loss.
4
Synthesize findings to identify the primary risk.
The client is exhibiting early compensatory signs of hypovolemic shock due to internal postoperative bleeding.
Recognizing early shock is critical to preventing progression to irreversible organ damage.
5
Determine the safest nursing action within the PN scope of practice.
The PN decides to withhold the scheduled anticoagulant and escalate the findings.
Administering enoxaparin would exacerbate the active bleeding. The PN must mitigate this risk by holding the medication and reporting the unstable condition to the RN.

Anahtar Kavram

Early recognition of hypovolemic shock and mitigation of bleeding risks
Tahmini Süre:2m 0s
Bu soruyu puanla

Konular

Reduction of Risk Potential

Bu konudan daha fazla soru