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Zorluk: KolayPhysiological Adaptation

An assistive personnel (AP) calls the practical nurse to the room of an 84-year-old client who had a bowel resection two days ago. The client, who was previously alert, is now highly restless and disoriented. The client's pulse is 110 beats/min and blood pressure is 96/58 mmHg. Which action should the practical nurse take first?

  1. Assess the client's airway, breathing, and oxygen saturation.Cevap
  2. B
    Administer the prescribed as-needed pain medication to calm the client.
  3. C
    Reassure the family that postoperative confusion is normal for older adults.
  4. D
    Record the vital signs in the chart since they are near normal limits.

Cevap

Assess the client's airway, breathing, and oxygen saturation.
Sudden restlessness and disorientation, combined with tachycardia and a borderline low blood pressure, are classic early signs of hypoxia or hypovolemic shock. According to the Airway, Breathing, and Circulation (ABC) priority framework, the nurse must first assess the client's respiratory and oxygenation status to rule out or treat life-threatening complications before pursuing other interventions.

Adım Adım Çözüm

1
Analyze the client's sudden change in mental status and vital signs.
The client is demonstrating signs of acute delirium, tachycardia, and borderline hypotension.
Sudden confusion and restlessness in a postoperative client are often early indicators of hypoxia or shock.
2
Determine the priority framework to apply to the situation.
The Airway, Breathing, Circulation (ABC) framework must be utilized.
Life-threatening physiological changes take priority over pain management, routine documentation, or family reassurance.
3
Select the action that addresses the highest priority physiological need.
Assessing airway, breathing, and oxygen saturation directly addresses the most critical potential cause of the client's symptoms.
Identifying and treating hypoxia or circulatory collapse is essential before taking any secondary nursing actions.

Anahtar Kavram

Prioritizing ABCs and recognizing early signs of physiological deterioration in postoperative clients.
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Konular

Physiological Adaptation

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