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Zorluk: OrtaPhysiological Adaptation

A practical nurse is gathering data on an older adult client who returned to the surgical unit 4 hours ago after a colon resection. The client's baseline vital signs were a blood pressure of 136/82 mm Hg and a pulse of 74 beats/min. Currently, the blood pressure is 108/66 mm Hg with a pulse of 102 beats/min. The client is continuously picking at the bed linens and complains of incisional pain. What is the priority nursing action?

  1. Notify the registered nurse of the client's current clinical status.Cevap
  2. B
    Administer the prescribed as-needed analgesic for the incisional pain.
  3. C
    Document the vital signs and plan to reassess them in one hour.
  4. D
    Reassure the family that temporary disorientation is expected for older clients after anesthesia.

Cevap

Notify the registered nurse of the client's current clinical status.
The correct action is to notify the registered nurse immediately because the client is exhibiting classic early signs of hypovolemic shock, including a narrowing pulse pressure, dropping blood pressure, increasing heart rate, and restlessness (altered mental status due to decreased cerebral perfusion). Immediate escalation is required to initiate fluid resuscitation or identify the source of bleeding.

Adım Adım Çözüm

1
Analyze the baseline versus current vital signs and physical findings.
The blood pressure has dropped, the heart rate has increased, and the client is showing signs of altered mental status (picking at linens).
Comparing current data to baseline is essential to identify trends indicating deterioration.
2
Determine the pathophysiological meaning of these findings.
The combination of tachycardia, dropping blood pressure, and restlessness indicates potential hypovolemic shock or internal bleeding.
Recognizing early shock allows for prompt intervention before cardiovascular collapse occurs.
3
Select the appropriate nursing action based on prioritization and scope of practice.
The priority is to immediately escalate these findings to the registered nurse for advanced assessment and collaborative intervention.
Circulation issues take precedence over pain management, and a practical nurse must report critical changes to the registered nurse.

Anahtar Kavram

Prioritization in early shock recognition
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Konular

Physiological Adaptation

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