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Zorluk: OrtaReduction of Risk Potential

A practical nurse is evaluating an adult client who underwent a percutaneous liver biopsy 22 hours prior. The client's baseline vital signs included a blood pressure of 124/78 mm Hg124/78\text{ mm Hg} and a heart rate of 76 beats/min76\text{ beats/min}. The nurse's current assessment reveals a blood pressure of 92/56 mm Hg92/56\text{ mm Hg} and a heart rate of 112 beats/min112\text{ beats/min}. The client reports feeling dizzy and having mild right shoulder pain. What is the priority nursing action?

  1. Alert the supervising registered nurse regarding the assessment findings.Cevap
  2. B
    Document the findings in the electronic health record and continue routine monitoring.
  3. C
    Assist the client into a left side-lying position to help relieve the shoulder discomfort.
  4. D
    Administer the prescribed as-needed oral pain medication for the reported shoulder pain.

Cevap

Alert the supervising registered nurse regarding the assessment findings.
The client's presentation of tachycardia, hypotension, dizziness, and right shoulder pain (referred pain from diaphragmatic irritation) are classic signs of internal hemorrhage following a liver biopsy. The practical nurse must immediately escalate these findings to the registered nurse for prompt intervention, as the client is exhibiting signs of impending hypovolemic shock and compromised circulation. Addressing the circulatory collapse is the absolute highest priority.

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1
Analyze the current vital signs and compare them to the client's pre-procedure baseline.
The blood pressure has dropped significantly and the heart rate has increased, indicating new-onset hypotension and tachycardia.
Identifying trends and recognizing deviations from the baseline is essential for detecting post-procedural complications.
2
Evaluate the client's reported symptoms (dizziness and right shoulder pain) in the context of a recent liver biopsy.
The lightheadedness correlates with the hypotension, and the right shoulder pain is a classic sign of referred pain from blood irritating the diaphragm.
Synthesizing objective vital sign data with subjective symptoms determines the clinical severity of the situation.
3
Determine the priority nursing action based on the practical nurse's scope of practice.
The clinical picture strongly suggests hemorrhagic shock, requiring immediate escalation to the registered nurse rather than independent symptomatic management.
The LPN must advocate for client safety by prioritizing airway, breathing, and circulation (ABCs) and reporting critical changes that require RN assessment and provider intervention.

Anahtar Kavram

Recognizing and Escalating Signs of Hemorrhagic Shock
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Konular

Reduction of Risk Potential

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