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Zorluk: OrtaPhysiological Adaptation

A practical nurse (PN) is monitoring an older adult client who is 12 hours post-operative following a total abdominal hysterectomy. The client suddenly becomes restless, appears mildly confused, and reports feeling 'out of breath.' Vital signs are heart rate 105 beats/minute, blood pressure 106/62 mm Hg, and respiratory rate 24 breaths/minute. Which action should the PN take first?

  1. Elevate the head of the bed and measure the client's oxygen saturation.Cevap
  2. B
    Reorient the client to the surroundings and explain that confusion is common after anesthesia.
  3. C
    Document the findings as expected borderline vital signs for the early postoperative period.
  4. D
    Examine the surgical dressing and linens for evidence of excessive bleeding.

Cevap

Elevate the head of the bed and measure the client's oxygen saturation.
The client is exhibiting early signs of hypoxia (restlessness, confusion, tachypnea, tachycardia), which is a potential life-threatening complication such as a pulmonary embolism or acute respiratory distress. Prioritizing the ABCs (Airway, Breathing, Circulation) requires the nurse to first support breathing by elevating the head of the bed to maximize lung expansion and immediately obtaining an oxygen saturation reading to quantify the level of hypoxia.

Adım Adım Çözüm

1
Analyze the clinical cues
The client is displaying new-onset restlessness, confusion, tachypnea (respiratory rate of 24), and tachycardia (heart rate of 105) alongside subjective shortness of breath.
Identifying abnormal, acute findings is the first step in recognizing physiological deterioration.
2
Apply the ABC (Airway, Breathing, Circulation) prioritization framework
The client's symptoms point to a potential breathing compromise (hypoxia) as the most immediate threat.
The ABC framework dictates that airway and breathing issues must be addressed before circulation or neurological issues.
3
Determine the most appropriate initial nursing intervention
Elevating the head of the bed promotes immediate lung expansion, and obtaining a pulse oximetry reading provides objective data about oxygenation status.
These actions provide immediate relief and essential data without delaying care or acting outside the practical nurse's scope of practice.

Anahtar Kavram

Prioritizing interventions based on the ABC (Airway, Breathing, Circulation) framework during acute physiological decompensation.
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Konular

Physiological Adaptation

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