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Zorluk: OrtaReduction of Risk Potential

An older adult client is receiving care on the surgical unit one day after a transurethral resection of the prostate (TURP). The client is currently restless and denies having any pain. The practical nurse obtains vital signs, noting a blood pressure of 96/60 mm Hg and a heart rate of 112 beats/minute. The client's preoperative baseline blood pressure was 138/82 mm Hg with a heart rate of 74 beats/minute. Which action should the nurse take first?

  1. Notify the supervising registered nurse immediately about the assessment findings.Cevap
  2. B
    Document the vital signs in the electronic health record and continue routine monitoring.
  3. C
    Increase the rate of the maintenance intravenous fluids to correct the hypotension.
  4. D
    Administer a prescribed as-needed sedative to manage the client's restlessness.

Cevap

The most appropriate initial action is to notify the supervising registered nurse immediately about the assessment findings.
The correct action is to notify the registered nurse immediately. A decreasing blood pressure, increasing heart rate, and new-onset restlessness in a postoperative client are classic early indicators of hypovolemic shock, likely due to bleeding. The practical nurse's role is to promptly identify these risk factors and escalate the situation to ensure client safety.

Adım Adım Çözüm

1
Analyze the client's current vital signs compared to the baseline.
The blood pressure has dropped significantly (from 138/82 to 96/60 mm Hg) and the heart rate has increased (from 74 to 112 beats/minute).
Recognizing trends in vital signs is essential to identify early physiological deterioration.
2
Evaluate the clinical significance of the physical assessment findings.
The client's unexplained restlessness, combined with tachycardia and hypotension, points to poor tissue perfusion.
Restlessness is often the earliest sign of hypoxia or hypovolemia, especially when the client denies pain.
3
Determine the priority nursing action within the practical nurse scope of practice.
The findings must be escalated to the registered nurse immediately.
The practical nurse must recognize signs of potential postoperative hemorrhage and shock, which require RN assessment and intervention.

Anahtar Kavram

Recognizing early signs of hypovolemic shock and prioritizing escalation of care within the practical nurse scope of practice.
Tahmini Süre:1m 15s
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Reduction of Risk Potential

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