A practical nurse is assigned to care for a client who is 3 days postoperative following a partial bowel resection. The client has a scheduled prescription for oral ketorolac for moderate pain. The client's morning laboratory report indicates a hemoglobin level of (a decrease from the previous day). The client's current vital signs are a blood pressure of , a heart rate of , and a respiratory rate of . The client reports abdominal pain and requests the scheduled medication. Which action should the practical nurse take first?
- Withhold the medication and immediately report the clinical findings to the registered nurse.Cevap
- BAdminister the scheduled medication to treat the pain, as uncontrolled pain is likely causing the elevated heart rate.
- CAdminister the medication and continue to monitor the client's vital signs closely for signs of hemodynamic instability.
- DWithhold the medication and document the laboratory results for the healthcare provider to review during routine rounds.
Cevap
The practical nurse should withhold the ketorolac and immediately report the vital signs and laboratory results to the registered nurse.
Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that carries a significant risk for gastrointestinal bleeding and can inhibit platelet function, especially in postoperative clients. The client's significant drop in hemoglobin, combined with borderline hypotension and tachycardia, strongly indicates potential internal hemorrhage. The practical nurse must prioritize circulation (from the ABCs) over pain management, withhold the medication that could exacerbate bleeding, and immediately escalate these critical findings to the registered nurse for urgent medical intervention.
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Anahtar Kavram
Recognizing signs of postoperative hemorrhage, prioritizing circulation over pain management, and adhering to safe medication administration practices regarding NSAIDs.