Examkin

Soru

Zorluk: ZorPhysiological Adaptation

Following shift report on a medical-surgical unit, a practical nurse (PN) reviews the data for four assigned clients. Which client's clinical presentation indicates a potential life-threatening complication and requires immediate escalation to the registered nurse (RN)?

  1. A
    A client with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 90%90\% on room air.
  2. B
    A client 11 day postoperative following an inguinal hernia repair who reports incisional pain rated 88 on a 00-to-1010 scale.
  3. A client with acute pancreatitis whose heart rate is 112112 beats/min and blood pressure is 98/6498/64 mm Hg.Cevap
  4. D
    A client with chronic kidney disease (CKD) scheduled for hemodialysis who has a serum potassium level of 5.25.2 mEq/L.

Cevap

The client with acute pancreatitis who has a heart rate of 112 beats/min and blood pressure of 98/64 mm Hg requires immediate escalation.
The client with acute pancreatitis is exhibiting tachycardia and hypotension. These are early, subtle signs of hypovolemic shock caused by massive fluid shifts (third-spacing) into the retroperitoneal cavity. This represents a life-threatening failure of physiological adaptation that requires immediate intravenous fluid resuscitation by the registered nurse.

Adım Adım Çözüm

1
Analyze the client with COPD.
The oxygen saturation is 90% on room air.
Identify that a pulse oximetry reading of 88-92% is an expected, stable baseline for a client with chronic respiratory disease.
2
Analyze the client who is 1 day postoperative.
The client has severe pain (8/10).
Recognize that acute postoperative pain is expected and does not represent a life-threatening airway, breathing, or circulation (ABC) emergency.
3
Analyze the client with CKD.
The serum potassium level is 5.2 mEq/L.
Identify that a slightly elevated potassium level is a baseline expectation for a renal failure client awaiting their scheduled dialysis session.
4
Analyze the client with acute pancreatitis.
The client exhibits a heart rate of 112 beats/min and a blood pressure of 98/64 mm Hg.
Determine that these borderline vital signs represent early hypovolemic shock caused by severe fluid shifting (third-spacing) into the retroperitoneum, making this the highest priority.

Anahtar Kavram

Prioritization requires distinguishing between expected chronic abnormalities and subtle, acute physiological deterioration such as early hypovolemic shock.
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru