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Zorluk: Çok zorReduction of Risk Potential

A licensed practical nurse (LPN) is monitoring a client who returned to the nursing unit 2 hours ago following an esophagogastroduodenoscopy (EGD) with a biopsy of esophageal varices. Which of the following assessment findings should the LPN identify as indicators of a potential complication requiring immediate escalation to the registered nurse (RN)? Select all that apply.

  1. Apical pulse of 114 beats/min and a blood pressure reading of 92/58 mm Hg.Cevap
  2. B
    Client reports mild throat discomfort and a raspy voice when answering questions.
  3. Continuous swallowing motions and repeated efforts to clear the airway.Cevap
  4. D
    A post-procedure serum potassium level of 4.1 mEq/L (4.1 mmol/L).
  5. A hemoglobin result of 8.4 g/dL (84 g/L), decreased from a baseline of 11.2 g/dL (112 g/L).Cevap
  6. F
    An oral temperature of 99.2°F (37.3°C) with unlabored respirations.

Cevap

The findings requiring immediate escalation are the elevated apical pulse with hypotension, continuous swallowing motions, and the significant decrease in hemoglobin.
Following an invasive biopsy of esophageal varices, the most immediate life-threatening complication is hemorrhage. The correct answers represent the triad of active bleeding indicators: hemodynamic instability (tachycardia with hypotension), behavioral signs of pooled blood in the airway (continuous swallowing), and objective laboratory confirmation of acute blood loss (precipitous drop in hemoglobin). Because these findings indicate an impending crisis, they must be escalated to the RN immediately for advanced intervention.

Adım Adım Çözüm

1
Analyze the clinical scenario and the specific procedure performed.
The client underwent an EGD with a biopsy of esophageal varices. Varices are enlarged, fragile veins that carry a massive risk of severe hemorrhage when traumatized.
Identifying the procedure's highest risk establishes the baseline for what complications to anticipate.
2
Evaluate the vital signs for indicators of hemodynamic instability.
An apical pulse of 114 beats/min combined with a blood pressure of 92/58 mm Hg indicates compensatory tachycardia and hypotension.
These are the hallmark signs of early hypovolemic shock secondary to acute blood loss.
3
Assess behavioral and physical cues that might indicate concealed bleeding.
The client is demonstrating continuous swallowing and throat clearing.
Because esophageal bleeding can drain silently into the stomach or pool in the throat, frequent swallowing is a primary indicator of active upper airway/GI bleeding.
4
Review the laboratory data for critical changes.
The hemoglobin dropped from 11.2 g/dL to 8.4 g/dL.
A rapid decrease of this magnitude confirms acute hemorrhage, requiring immediate provider notification for potential blood transfusion and surgical intervention.
5
Differentiate expected post-procedure findings from emergent complications.
Mild throat discomfort, a low-grade temperature (99.2°F), and a normal potassium level (4.1 mEq/L) are identified as expected or normal findings.
The LPN must avoid overreacting to routine post-operative physiological responses to maintain focus on true life-threatening emergencies.

Anahtar Kavram

Post-Procedure Hemorrhage Recognition and Escalation
Tahmini Süre:2m 0s
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Konular

Reduction of Risk Potential

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