Examkin

Soru

Zorluk: ZorReduction of Risk Potential

A practical nurse (PN) is performing a morning assessment on an older adult client who is 48 hours post-operative following a total hip arthroplasty. Which of the following findings indicate a potential complication and require immediate escalation to the registered nurse (RN)? Select all that apply.

  1. The client, who was alert yesterday, repeatedly asks the nurse where they are.Cevap
  2. Heart rate is 112 beats per minute with a blood pressure of 98/60 mm Hg.Cevap
  3. Morning laboratory results indicate a serum potassium level of 2.8 mEq/L (2.8 mmol/L).Cevap
  4. D
    The client reports a pain level of 4 on a 0 to 10 scale during physical therapy exercises.
  5. E
    The surgical dressing has a 3-centimeter area of dry, dark brown drainage.
  6. F
    The client's heels are resting directly on the surface of the mattress.

Cevap

The findings requiring immediate RN escalation are the sudden-onset confusion, the vital signs of 112 bpm and 98/60 mm Hg, and the serum potassium level of 2.8 mEq/L.
Sudden-onset confusion in an older adult is an indicator of acute delirium, potentially caused by hypoxia or infection. A heart rate of 112 beats per minute with a blood pressure of 98/60 mm Hg represents borderline vital signs that are early indicators of hypovolemic shock or hemorrhage. A serum potassium level of 2.8 mEq/L is critically low and places the client at immediate risk for life-threatening cardiac dysrhythmias. All three of these findings represent acute, potentially life-threatening complications that exceed the practical nurse's scope of independent management and require immediate escalation to the registered nurse.

Adım Adım Çözüm

1
Analyze the client's cognitive change.
Sudden confusion indicates potential acute delirium, hypoxia, or infection.
New-onset disorientation is never a normal finding and requires urgent assessment to rule out life-threatening causes.
2
Evaluate the vital signs.
A heart rate of 112 bpm with a blood pressure of 98/60 mm Hg suggests early hypovolemia or shock.
Borderline tachycardia and hypotension in a post-operative client are early compensatory signs of hemorrhage that must be escalated.
3
Review the laboratory results.
A potassium level of 2.8 mEq/L is critically low.
Hypokalemia can trigger fatal cardiac dysrhythmias and requires immediate medical intervention.
4
Evaluate the remaining clinical findings.
Mild pain with movement, small amounts of dry drainage, and incorrect heel positioning are expected or easily correctable findings.
These findings fall within the practical nurse's scope to manage independently (e.g., administering PRN analgesics, floating heels) and do not require urgent RN escalation.

Anahtar Kavram

Recognizing early clinical indicators of post-operative complications and differentiating them from expected findings or issues within the practical nurse's independent scope.
Bu soruyu puanla

Konular

Reduction of Risk Potential

Bu konudan daha fazla soru