Examkin

Soru

Zorluk: ZorReduction of Risk Potential

A practical nurse (PN) is caring for a client who is 4 hours post-operative following a partial bowel resection. The client's preoperative blood pressure was 122/76 mm Hg with a heart rate of 74 bpm. Current vital signs are: blood pressure 94/58 mm Hg, heart rate 114 bpm, respiratory rate 20 breaths/min, and temperature 98.8°F (37.1°C). The client reports mild nausea and incisional pain rated as 3 on a 0 to 10 scale. Which action should the PN take first?

  1. Notify the registered nurse (RN) immediately about the changes in the client's vital signsCevap
  2. B
    Reassess the client's blood pressure and heart rate in 30 minutes
  3. C
    Increase the rate of the continuous intravenous (IV) normal saline infusion
  4. D
    Administer the prescribed PRN antiemetic medication for the client's nausea

Cevap

Notify the registered nurse (RN) immediately about the changes in the client's vital signs
The correct answer is to notify the registered nurse immediately because the client is exhibiting classic early signs of hypovolemic shock or internal bleeding (tachycardia and a significant decrease in blood pressure from baseline) just 4 hours after a major abdominal surgery. The PN must prioritize client safety by recognizing these risk factors and escalating the situation to ensure timely medical intervention.

Adım Adım Çözüm

1
Compare current vital signs to the preoperative baseline.
Identified a significant drop in blood pressure and a notable increase in heart rate.
To detect early physiological changes that may indicate a developing postoperative complication.
2
Analyze the findings within the clinical context of a recent bowel resection.
Recognized that new-onset tachycardia and relative hypotension are early indicators of fluid volume deficit, hemorrhage, or shock.
To determine the clinical significance and urgency of the vital sign changes.
3
Determine the priority PN action based on scope of practice and client safety.
Decided to immediately escalate the findings to the supervising RN.
Because managing a potentially hemodynamically unstable client requires RN-level assessment and collaborative intervention to reduce the risk of severe complications.

Anahtar Kavram

Early recognition and escalation of postoperative complications (shock/hemorrhage) within the PN scope of practice.
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Konular

Reduction of Risk Potential

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