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Soru

Zorluk: Çok zorReduction of Risk Potential

An adult client is recovering on the medical-surgical unit 4 hours after an ultrasound-guided percutaneous liver biopsy. The client is currently positioned on their right side and reports new-onset right shoulder pain along with feeling 'anxious.' The practical nurse assesses the client and notes a heart rate of 112 bpm, blood pressure of 104/62 mm Hg, and a respiratory rate of 22 breaths per minute. Baseline vitals before the procedure were a heart rate of 76 bpm, blood pressure of 136/78 mm Hg, and a respiratory rate of 14 breaths per minute. Based on these findings, which action is the priority for the practical nurse?

  1. A
    Administer the prescribed as-needed analgesic to treat the client's right shoulder pain
  2. B
    Document the vital signs in the electronic health record and repeat the assessment in one hour
  3. Immediately alert the registered nurse of the clinical changes to initiate emergency escalationCevap
  4. D
    Reposition the client from the right lateral side to a semi-Fowler's position to alleviate anxiety

Cevap

Immediately alert the registered nurse of the clinical changes to initiate emergency escalation
The correct action involves notifying the registered nurse immediately because the client is exhibiting classic signs of internal hemorrhage and early hypovolemic shock. Following a liver biopsy, the organ is highly vascular and prone to bleeding. The new-onset right shoulder pain is referred pain resulting from blood pooling and irritating the phrenic nerve under the diaphragm. Combined with increasing restlessness, a rising heart rate, and a dropping blood pressure compared to the baseline, these findings require immediate emergency escalation rather than independent nursing interventions.

Adım Adım Çözüm

1
Analyze the client's recent procedure (liver biopsy) and identify the primary post-procedure risk.
The highest risk following a percutaneous liver biopsy is internal hemorrhage due to the high vascularity of the liver.
Anticipating complications allows the nurse to interpret assessment data accurately.
2
Evaluate the new-onset symptoms of right shoulder pain and anxiety.
Anxiety is an early sign of hypoxia or shock. Right shoulder pain is referred pain caused by blood accumulating under the diaphragm and irritating the phrenic nerve.
Recognizing referred pain helps differentiate a severe complication from benign musculoskeletal discomfort.
3
Compare the current vital signs to the client's pre-procedure baseline.
The heart rate increased by 36 bpm and the systolic blood pressure dropped by 32 mm Hg. Combined with the symptoms, this indicates early compensatory hypovolemic shock.
Absolute vital sign numbers can be misleading; recognizing significant shifts from baseline is critical for detecting shock early.
4
Determine the safest and most appropriate intervention within the practical nurse's scope of practice.
The priority is to maintain the pressure-holding right lateral position and immediately escalate the critical findings to the registered nurse for emergency intervention.
The client requires rapid medical evaluation, fluid resuscitation, and potentially surgical intervention, which necessitates immediate escalation.

Anahtar Kavram

Identifying early signs of hemorrhage and hypovolemic shock following invasive procedures and prioritizing immediate escalation.
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Konular

Reduction of Risk Potential

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