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Soru

Zorluk: ZorReduction of Risk Potential

A client is recovering on the surgical unit 4 hours after undergoing a laparoscopic cholecystectomy. The client reports right shoulder discomfort and a feeling of tightness in the abdomen. The most recent vital signs reveal a temperature of 99.2°F (37.3°C), a heart rate of 106/min, a blood pressure of 102/64 mm Hg, and a respiratory rate of 20/min. Preoperative baseline vital signs were a heart rate of 74/min and a blood pressure of 136/78 mm Hg. Which action should the practical nurse take first?

  1. Notify the supervising registered nurse about the altered vital signs and physical symptomsCevap
  2. B
    Help the client walk around the room to promote the absorption of retained surgical gas
  3. C
    Elevate the head of the bed to a high-Fowler's angle to ease the sensation of abdominal fullness
  4. D
    Adjust the continuous intravenous fluid infusion to a faster rate to address the decreasing blood pressure

Cevap

Notify the supervising registered nurse about the altered vital signs and physical symptoms
The client is exhibiting early signs of hypovolemic shock, evidenced by tachycardia and a significant drop in blood pressure from the baseline, along with abdominal tightness. These are potential indicators of internal bleeding following abdominal surgery. While right shoulder pain can be an expected finding due to retained carbon dioxide, the combination of these vital sign changes requires immediate escalation to the registered nurse for urgent evaluation and intervention.

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1
Analyze the client's symptoms and vital signs.
The client has right shoulder pain, abdominal tightness, tachycardia (106/min), and relative hypotension (102/64 mm Hg) compared to a baseline blood pressure of 136/78 mm Hg.
Recognizing deviations from baseline is essential for the early identification of postoperative complications.
2
Differentiate expected postoperative findings from potential emergencies.
While shoulder pain can be a benign result of carbon dioxide used during laparoscopy, the accompanying abdominal tightness, significantly increased heart rate, and decreased blood pressure strongly point toward internal hemorrhage.
Hypovolemia from internal bleeding presents with compensatory tachycardia and dropping blood pressure, which takes priority over benign gas pain.
3
Determine the appropriate nursing action within the practical nurse scope of practice.
The practical nurse must immediately escalate these critical findings to the registered nurse for a comprehensive assessment and provider notification.
A hemodynamically unstable client requires registered nurse-level assessment, clinical judgment, and urgent medical intervention.

Anahtar Kavram

Recognizing Early Signs of Shock and Escalation
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Konular

Reduction of Risk Potential

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