A practical nurse (PN) is performing hourly rounds on a medical-surgical unit. Which of the following client assessment findings represent an increased risk for physiological instability and require immediate escalation to the registered nurse (RN)? Select all that apply.
- A client hours post-thyroidectomy who reports new-onset numbness and tingling around the lipsCevap
- A client receiving intravenous antibiotics whose blood pressure decreased from to over the past two hoursCevap
- CA client hours post-total knee arthroplasty who has a morning hemoglobin level of ()
- A client with a casted lower extremity who reports deep, throbbing pain that is unrelieved by the prescribed opioid analgesicCevap
- EA client with an indwelling urinary catheter that has drained of clear yellow urine over the last hours
- FA client prescribed a daily oral beta-blocker who has a resting apical pulse of prior to administration
Cevap
The correct findings that require immediate escalation are the client post-thyroidectomy with lip numbness, the client with a dropping blood pressure on antibiotics, and the client with cast pain unrelieved by opioids.
Escalation to the RN is required for findings that indicate impending physiological collapse or permanent tissue damage. Numbness around the lips after a thyroidectomy signals hypocalcemia, which can progress to tetany and airway obstruction. A sudden drop in blood pressure while receiving antibiotics indicates potential anaphylaxis or sepsis. Severe, unrelieved pain in a casted extremity is a classic sign of compartment syndrome, which can lead to limb loss if not addressed immediately.
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Anahtar Kavram
Identifying early indicators of physiological instability and escalating critical findings within the PN scope of practice to reduce client risk.