Examkin

Soru

Zorluk: ZorPhysiological Adaptation

A 72-year-old client is receiving continuous intravenous normal saline at 125 mL/hr for the treatment of gastroenteritis. The practical nurse enters the room and observes that the client is restless, slightly confused, and has developed a new, frequent moist cough. The client is using accessory muscles to breathe. The practical nurse collects the following vital signs:

- Blood pressure: 162/94 mm Hg (Baseline: 118/76 mm Hg)
- Heart rate: 108 bpm (Baseline: 84 bpm)
- Respiratory rate: 28 breaths/min (Baseline: 18 breaths/min)
- Oxygen saturation: 90% on room air (Baseline: 96%)

Which of the following actions should the practical nurse take first?

  1. A
    Document the vital signs as a transient response to coughing and reassess the client in 30 minutes.
  2. B
    Pause the intravenous fluids and auscultate the client's abdomen to evaluate the resolving gastroenteritis.
  3. C
    Reassure the client that confusion and restlessness are common in unfamiliar hospital settings and encourage rest.
  4. Assist the client into a high-Fowler's position and notify the registered nurse immediately.Cevap

Cevap

The correct action is to assist the client into a high-Fowler's position and notify the registered nurse immediately.
The client's assessment findings (hypertension, tachycardia, tachypnea, hypoxia, moist cough, and restlessness) strongly indicate fluid volume overload and acute pulmonary edema secondary to the intravenous fluid infusion. The most immediate, independent action the practical nurse can take to support the 'Breathing' component of ABCs is to place the client in a high-Fowler's position. This facilitates maximum lung expansion and reduces venous return to the heart, decreasing pulmonary congestion. Immediately notifying the registered nurse is crucial, as the client is unstable and will require collaborative interventions such as oxygen therapy, stopping the infusion, and administering diuretics.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and vital sign trends.
The client demonstrates hypertension, tachycardia, tachypnea, hypoxia, a moist cough, and altered mental status (restlessness/confusion).
Recognizing the combination of these symptoms points toward fluid volume overload progressing to acute pulmonary edema, a medical emergency.
2
Prioritize interventions using the Airway, Breathing, and Circulation (ABC) framework.
Breathing is the immediate priority due to the oxygen saturation of 90% and use of accessory muscles.
Without adequate oxygenation, cellular death can occur rapidly. Mechanical improvement of breathing takes precedence over routine assessments.
3
Determine the most appropriate immediate, independent nursing action within the practical nurse scope of practice.
Placing the client in a high-Fowler's position.
This position drops the diaphragm to maximize lung expansion and uses gravity to decrease venous return to the right side of the heart, reducing pulmonary congestion.
4
Identify the next required collaborative step.
Notify the registered nurse immediately.
The client's condition is unstable and requires interventions beyond the practical nurse scope, such as administering intravenous diuretics or advanced oxygen therapy.

Anahtar Kavram

Recognition and immediate prioritization of acute pulmonary edema and fluid volume overload in the elderly.
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru