Examkin

Soru

Zorluk: OrtaPhysiological Adaptation

A practical nurse is providing care for a 75-year-old client who had a bowel resection two days ago. The client's morning vital signs were: blood pressure 104/68 mm Hg, heart rate 96 beats/min, respirations 20 breaths/min, and oxygen saturation 94% on room air. Two hours later, the client suddenly becomes highly restless, confused, and attempts to climb out of bed. Which action should the practical nurse take first?

  1. A
    Dim the room lights, speak softly, and provide a calming environment
  2. B
    Document the change in mental status as expected postoperative delirium
  3. Obtain a current set of vital signs including oxygen saturationCevap
  4. D
    Assess the client for incisional pain and administer a prescribed analgesic

Cevap

The priority action is to obtain a current set of vital signs including oxygen saturation.
Sudden restlessness and confusion in a postoperative client are classic early signs of hypoxia, hemorrhage, or hypovolemic shock. Because the morning vital signs were already borderline (heart rate of 96 beats/min and oxygen saturation of 94%), the nurse must first collect current physiologic data to determine if the client is rapidly decompensating. This objective data is essential before notifying the registered nurse or the healthcare provider.

Adım Adım Çözüm

1
Analyze the baseline clinical data.
The morning vital signs showed a high-normal heart rate and low-normal oxygen saturation, indicating the client was in a borderline compensated state.
Establishing a baseline helps identify subtle trends that precede sudden clinical deterioration.
2
Interpret the new onset of symptoms.
Sudden restlessness and confusion in an older adult are often the first signs of impaired tissue perfusion (shock) or hypoxia.
The brain is highly sensitive to drops in oxygenation and blood flow, presenting as altered mental status before other overt signs appear.
3
Determine the priority nursing intervention.
The practical nurse must first collect objective data regarding airway, breathing, and circulation (vital signs).
According to ABC prioritization, verifying physiologic stability is required before implementing comfort measures or behavioral interventions.

Anahtar Kavram

Prioritization of Care and Acute Shock Recognition
Tahmini Süre:1m 0s
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru