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Zorluk: OrtaPhysiological Adaptation

During routine hourly rounds, a practical nurse evaluates a 42-year-old client who returned from a total abdominal hysterectomy 4 hours ago. The client appears very restless and requests water, stating they are extremely thirsty. The client's heart rate has increased from 82 to 110 beats per minute over the past hour, while the blood pressure is currently 108/68 mm Hg. What is the most appropriate initial action for the nurse to take?

  1. Inspect the surgical dressing and perineal pad for evidence of excessive bleedingCevap
  2. B
    Provide a small amount of ice chips to alleviate the client's severe thirst
  3. C
    Document the current vital signs as an expected early postoperative response
  4. D
    Assist the client into a high-Fowler's position to promote optimal comfort

Cevap

Inspect the surgical dressing and perineal pad for evidence of excessive bleeding
The correct action is to inspect the surgical dressing and perineal pad. The client's restlessness, severe thirst, and increasing heart rate (tachycardia) are classic early compensatory signs of hypovolemic shock, often caused by internal or external hemorrhage following major surgery. Even though the blood pressure is currently maintained, the nurse must immediately assess for the source of potential bleeding to gather critical data before notifying the registered nurse or provider.

Adım Adım Çözüm

1
Analyze the client's new clinical signs: restlessness, extreme thirst, and an increasing heart rate.
Identify that these are classic early compensatory signs of hypovolemic shock.
Recognizing early shock is critical before the blood pressure begins to drop.
2
Determine the most likely cause of hypovolemia in a client 4 hours post-hysterectomy.
The most likely cause is postoperative hemorrhage.
Surgical patients are at high risk for internal or external bleeding in the immediate postoperative period.
3
Select the nursing action that prioritizes assessing the circulatory status.
The nurse must inspect the operative site and perineum for bleeding.
Direct assessment of the surgical site provides critical data about potential hemorrhage to report to the registered nurse.

Anahtar Kavram

Early recognition and assessment of hypovolemic shock
Tahmini Süre:1m 0s
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Konular

Physiological Adaptation

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