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Soru

Zorluk: OrtaReduction of Risk Potential

During bedside handoff, a practical nurse assumes care for a client who underwent an open bowel resection 4 hours ago. The client is receiving continuous intravenous fluids. Upon initial assessment, the client reports incisional pain of 7 on a 0 to 10 scale. The electronic health record displays the following recent vital signs: blood pressure 98/62 mm Hg, heart rate 118/min, respirations 20/min, and oxygen saturation 95% on room air.

Which of the following actions should the practical nurse take? Select all that apply.

  1. Alert the supervising registered nurse about the current heart rate and blood pressure values.Cevap
  2. B
    Give the prescribed intravenous push (IVP) hydromorphone to alleviate the client's postoperative pain.
  3. Examine the client's surgical dressing and the dependent linens for evidence of active hemorrhage.Cevap
  4. D
    Record the assessment data in the electronic health record and wait until the next routine interval to recheck vital signs.
  5. E
    Flex the client's knees sharply using the bed positioning controls to relieve pulling on the abdominal incision.
  6. Utilize the electronic barcode scanner to match the client's wristband with the medication packaging before giving oral antibiotics.Cevap

Cevap

The correct actions are to alert the registered nurse about the vital signs, examine the dressing and linens for hemorrhage, and utilize the barcode scanner for medication administration.
The correct actions prioritize client safety by recognizing and responding to early signs of hypovolemic shock. A heart rate of 118/min with a blood pressure of 98/62 mm Hg warrants immediate escalation to the registered nurse and targeted data collection for bleeding (inspecting the dressing and dependent linens). Additionally, using barcode scanning for all medication administration is a fundamental risk-reduction strategy.

Adım Adım Çözüm

1
Analyze the client's postoperative vital signs.
The heart rate of 118/min and blood pressure of 98/62 mm Hg indicate tachycardia and borderline hypotension.
These findings are early compensatory mechanisms for hypovolemia or active hemorrhage, which require immediate clinical attention rather than routine monitoring.
2
Determine the appropriate practical nursing interventions for the identified risk.
The practical nurse must escalate the findings to the registered nurse and gather focused data by checking the surgical site and dependent linens for bleeding.
Timely communication and targeted data collection reduce the risk of severe complications from delayed treatment.
3
Evaluate other standard care actions against the practical nurse scope of practice and safety protocols.
Intravenous push medications must be avoided, knee flexion must be minimized to prevent deep vein thrombosis, and barcode scanning must be used for oral medications.
Adhering strictly to the legal scope of practice and evidence-based safety guidelines minimizes the potential for adverse events.

Anahtar Kavram

Early recognition of postoperative complications and adherence to the practical nurse scope of practice are essential to risk reduction.
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Reduction of Risk Potential

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