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Zorluk: ZorPhysiological Adaptation

A practical nurse (PN) is performing a follow-up assessment on a client who underwent a Roux-en-Y gastric bypass 14 hours ago. Which clinical finding represents an acute decompensation that the PN must immediately escalate to the registered nurse?

  1. A resting heart rate of 116 beats/min accompanied by new-onset restlessness.Cevap
  2. B
    A reported pulling sensation and pain rated 6 out of 10 at the laparoscopic port sites.
  3. C
    Scattered basilar lung crackles that completely clear after the client coughs deeply.
  4. D
    A documented urine output of 140 mL in the collection bag over the last three hours.

Cevap

A resting heart rate of 116 beats/min accompanied by new-onset restlessness.
After major abdominal or bariatric surgery, an unexplained increase in heart rate (tachycardia) and acute neurological changes (restlessness, anxiety) are classic, early indicators of systemic compromise. These findings strongly suggest severe complications such as hemorrhage, an anastomotic leak, or developing peritonitis. Because this represents an acute threat to the client's circulation and tissue perfusion (ABCs), the PN must escalate this immediately to the RN for rapid medical intervention.

Adım Adım Çözüm

1
Analyze the client's postoperative timeframe and specific surgical risks.
The client is 14 hours post-Roux-en-Y gastric bypass, placing them at high risk for hemorrhage or an anastomotic leak.
Recognizing procedure-specific risks guides the prioritization of assessment data.
2
Evaluate the clinical findings in each option for life-threatening complications (ABCs).
A heart rate of 116 beats/min and new restlessness indicate inadequate tissue perfusion or systemic infection.
Tachycardia is often the earliest physiological adaptation to shock, hemorrhage, or peritonitis.
3
Compare the abnormal systemic findings against expected or stable postoperative symptoms.
Incisional pain (6/10), clearable lung crackles, and adequate urine output (~46 mL/hr) are expected or stable findings.
Expected clinical findings do not take priority over impending cardiovascular or respiratory collapse.

Anahtar Kavram

Prioritization of early shock indicators (tachycardia, restlessness) over expected postoperative findings.
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Konular

Physiological Adaptation

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