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Zorluk: OrtaPhysiological Adaptation

A practical nurse (PN) is monitoring a client who underwent a percutaneous coronary intervention via the right femoral artery three hours ago. The client states, "I feel really thirsty and a little dizzy." The PN notes the client's heart rate has gradually increased from a baseline of 74 bpm to 108 bpm, and blood pressure has trended from 132/80 mm Hg to 104/62 mm Hg. Which action should the PN perform first?

  1. Examine the right femoral access site and palpate the surrounding tissue.Cevap
  2. B
    Provide a small cup of water to relieve the client's complaints of thirst.
  3. C
    Review the medication administration record for recently given sedatives.
  4. D
    Ask the client to rate any back or groin pain on a scale of 0 to 10.

Cevap

Examine the right femoral access site and palpate the surrounding tissue.
The correct answer focuses on immediate assessment of the procedural site because the client is demonstrating classic early signs of compensatory shock (tachycardia, narrowing pulse pressure, mild hypotension, thirst, and dizziness). Following a femoral artery puncture, the most immediate life-threatening risk is hemorrhage or retroperitoneal bleeding. Assessing the site directly addresses the 'Circulation' component of the ABC priority framework.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and vital sign trends.
The client has developed tachycardia, mild hypotension, dizziness, and thirst compared to baseline.
Recognizing early physiological changes is essential for identifying acute complications like hypovolemia.
2
Connect the symptoms to the recent procedure.
The client had a femoral artery puncture, placing them at high risk for hemorrhage or hematoma formation.
Identifying the most life-threatening complication related to the procedure determines the priority assessment.
3
Prioritize the next nursing action based on the ABCs (Airway, Breathing, Circulation).
The nurse must immediately assess the insertion site for bleeding to evaluate the client's circulatory status.
Intervening to identify and stop potential hemorrhage takes precedence over routine care or symptom management.

Anahtar Kavram

Early recognition of hypovolemic shock following an arterial procedure.

Alternatif Yöntem

Use the ABC (Airway, Breathing, Circulation) prioritization framework. Since airway and breathing are not compromised in this scenario, the priority shifts to circulation. The vital signs indicate a circulatory problem, leading directly to assessing the site of potential bleeding.
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Physiological Adaptation

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