Examkin

Soru

Zorluk: OrtaPhysiological Adaptation

An unlicensed assistive personnel (UAP) reports the morning vital signs for an older adult client who underwent a right total hip arthroplasty the previous day. The client's heart rate is 114 beats per minute and blood pressure is 98/62 mm Hg. The UAP also mentions that the client is newly disoriented to place. Which action should the practical nurse take first?

  1. Examine the surgical dressing and the bed linens beneath the client's right hip.Cevap
  2. B
    Explain to the client that mild hypotension and an elevated heart rate are expected after anesthesia.
  3. C
    Administer the prescribed as-needed oral opioid analgesic to promote client comfort.
  4. D
    Document the client's altered mental status as a routine age-related cognitive change.

Cevap

The correct action is to examine the surgical dressing and the bed linens beneath the client's right hip.
Tachycardia, hypotension, and new-onset confusion in a postoperative client are classic early signs of hypovolemic shock, most commonly caused by hemorrhage in this clinical context. The practical nurse must immediately collect data regarding potential bleeding sources by inspecting the surgical site and the dependent areas (linens underneath) where blood typically pools due to gravity.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
Recognize that tachycardia, hypotension, and new-onset confusion indicate compromised tissue perfusion.
Early recognition of shock is essential to prevent irreversible organ damage.
2
Determine the most likely cause of hypovolemia.
Identify hemorrhage as the primary risk factor following a major orthopedic surgery.
Postoperative bleeding is a common and life-threatening complication of hip arthroplasty.
3
Select the priority nursing action based on the identified risk.
Choose to physically examine the surgical dressing and dependent bed linens.
Blood can pool under the client without being visible on the top dressing, necessitating a thorough assessment before escalating to the registered nurse.

Anahtar Kavram

Early Recognition of Hypovolemic Shock and Hemorrhage
Tahmini Süre:1m 0s
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru