Examkin

Soru

Zorluk: ZorReduction of Risk Potential

Following a motor vehicle collision, a client with a confirmed pelvic fracture is admitted to the progressive care unit. During the morning assessment, the practical nurse reviews the client's laboratory results, which reveal a hemoglobin level of 9.2 g/dL (92 g/L). The nurse notes that the client has produced only 80 mL of urine over the previous 4 hours. Current vital signs include a heart rate of 118 beats/minute, blood pressure of 102/64 mm Hg, and respiratory rate of 22 breaths/minute. The client suddenly reports an intense, new sensation of pressure in the pelvic region. Which of the following actions should the practical nurse take first?

  1. A
    Document the morning laboratory results in the electronic health record for the healthcare provider to review.
  2. B
    Administer the prescribed oral analgesic medication to manage the new onset of severe pelvic pressure.
  3. Notify the registered nurse immediately about the clinical findings and the client's reported symptoms.Cevap
  4. D
    Increase the continuous intravenous fluid infusion rate to compensate for the low urinary output.

Cevap

Notify the registered nurse immediately about the clinical findings and the client's reported symptoms.
Notifying the registered nurse immediately is the correct action because the client is exhibiting multiple indicators of hypovolemic shock secondary to retroperitoneal hemorrhage. The combination of tachycardia, borderline hypotension, oliguria (urine output less than 30 mL/hr), low hemoglobin, and a new onset of intense pelvic pressure indicates a life-threatening emergency. The practical nurse must promptly escalate these findings to the registered nurse so that rapid, advanced interventions, such as fluid resuscitation, blood transfusions, or surgical stabilization, can be initiated.

Adım Adım Çözüm

1
Analyze the client's vital signs and urine output.
Tachycardia, borderline hypotension, and oliguria are present.
To identify early signs of systemic instability or compensatory shock.
2
Evaluate the laboratory results and client symptoms in the context of the initial injury.
A low hemoglobin level and new, intense pelvic pressure strongly indicate active retroperitoneal bleeding from the pelvic fracture.
To correlate subjective complaints and objective data with the high risk of hemorrhage.
3
Determine the appropriate clinical response within the practical nurse scope of practice.
The client is experiencing a life-threatening emergency requiring advanced clinical judgment and rapid intervention.
To ensure the client receives immediate care from the registered nurse or healthcare provider.

Anahtar Kavram

Recognition and Escalation of Hemorrhagic Shock
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Konular

Reduction of Risk Potential

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