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Zorluk: OrtaReduction of Risk Potential

A client is receiving care on an orthopedic unit following a closed pelvic fracture sustained in a fall. During evening rounds, the licensed practical nurse notes the following vital signs: blood pressure 96/62 mm Hg, heart rate 118 beats/min, respiratory rate 18 breaths/min, and oral temperature 98.8°F (37.1°C). Which nursing action is the most appropriate next step?

  1. Report the vital sign parameters to the registered nurse immediately.Cevap
  2. B
    Document the findings as an expected stress response and recheck in four hours.
  3. C
    Administer the prescribed as-needed oral opioid analgesic for suspected pain.
  4. D
    Perform a comprehensive physical assessment to identify the source of fluid loss.

Cevap

The most appropriate next step is to report the vital sign parameters to the registered nurse immediately.
The correct action is to report the vital signs to the registered nurse immediately. Tachycardia (heart rate of 118 beats/min) and borderline hypotension (blood pressure of 96/62 mm Hg) in a client with a pelvic fracture are early clinical indicators of internal hemorrhage and hypovolemic shock. Pelvic fractures carry a high risk of significant concealed blood loss, requiring prompt RN assessment and provider notification to mitigate severe, life-threatening complications.

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1
Analyze the client's vital signs in the context of their injury.
The heart rate is significantly elevated (118 beats/min) and blood pressure is borderline low (96/62 mm Hg) for an adult.
Recognizing abnormal physiological parameters is the first step in clinical reasoning and risk reduction.
2
Correlate the findings with the client's diagnosis of a closed pelvic fracture.
Pelvic fractures carry a high risk of massive internal hemorrhage, which presents initially as compensatory tachycardia and hypotension.
Connecting the diagnosis to potential complications identifies the severe risk of hypovolemic shock.
3
Determine the appropriate scope of practice and priority action.
The practical nurse must immediately escalate these critical, unstable findings to the registered nurse.
Unstable clients with early signs of shock require RN-level assessment and rapid provider intervention.

Anahtar Kavram

Early recognition and escalation of hypovolemic shock indicators
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Konular

Reduction of Risk Potential

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