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Zorluk: OrtaReduction of Risk Potential

Following a percutaneous liver biopsy, a client's electronic health record displays the following vital sign progression:

TimepointBlood Pressure (mm Hg)Apical Pulse (beats/min)
Pre-procedure128/7672
1 hour post-procedure116/7088
2 hours post-procedure (Current)102/64104

The client currently appears pale and states, "I feel a little dizzy when I turn my head." Which immediate action should the practical nurse take?

  1. Notify the registered nurse of the vital sign trends and client symptomsCevap
  2. B
    Document the findings as the current blood pressure remains above 100 systolic
  3. C
    Assist the client to a sitting position on the edge of the bed to evaluate orthostatic changes
  4. D
    Independently increase the rate of the client's maintenance intravenous fluids

Cevap

The correct action is to notify the registered nurse of the vital sign trends and client symptoms.
The client's trending vital signs (decreasing blood pressure and increasing heart rate) combined with pallor and dizziness strongly indicate early hypovolemic shock, a potential and life-threatening complication of internal hemorrhage following a liver biopsy. The practical nurse must immediately escalate these critical findings to the registered nurse or healthcare provider to ensure rapid medical intervention.

Adım Adım Çözüm

1
Analyze the vital sign trends over the two-hour post-procedure period.
Blood pressure dropped from 128/76 to 102/64 mm Hg, and the heart rate increased from 72 to 104 beats/min.
Comparing current data to baseline is essential to identify early physiological deterioration.
2
Correlate the vital sign changes with the client's physical symptoms and recent procedure.
The combination of tachycardia, relative hypotension, pallor, and dizziness after a highly vascular liver biopsy suggests internal bleeding.
Recognizing the systemic signs of hypovolemic shock allows for prompt escalation and risk reduction.
3
Determine the safest and most appropriate nursing intervention within the practical nurse scope.
The most critical action is to immediately notify the registered nurse or healthcare provider.
Suspected internal hemorrhage is a life-threatening emergency requiring advanced assessment and medical orders beyond the practical nurse's independent scope.

Anahtar Kavram

Early Recognition of Hypovolemic Shock
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Konular

Reduction of Risk Potential

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