While organizing the shift workload on an acute medical-surgical unit, a licensed practical nurse reviews the status of four assigned individuals. Which action represents the highest priority to mitigate a potential life-threatening complication?
- AIndependently developing and documenting the initial comprehensive discharge education plan for an individual recently diagnosed with congestive heart failure
- BWithholding a scheduled dose of oral furosemide and contacting the healthcare provider because the client's morning serum potassium level is 4.5 mEq/L (4.5 mmol/L)
- Notifying the charge nurse about a postoperative client who has developed new-onset restlessness, a heart rate of 116 beats per minute, and a blood pressure of 94/58 mm HgCevap
- DBypassing the electronic barcode medication administration system to quickly administer a routine daily supplement before the client leaves for a therapy session
Cevap
The most critical action is notifying the charge nurse about the postoperative client exhibiting new-onset restlessness, tachycardia, and hypotension, as these are clear indicators of impending shock.
The postoperative client is exhibiting early signs of hypovolemic or hemorrhagic shock, characterized by restlessness (due to decreased cerebral perfusion), tachycardia (a compensatory mechanism to maintain cardiac output), and hypotension. Immediate escalation to the charge nurse or provider is required to initiate interventions and prevent cardiovascular collapse. Addressing this immediate physiological threat directly reduces the most severe risk of potential harm.
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Anahtar Kavram
Early Recognition of Hypovolemic Shock and Adherence to Scope of Practice