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Soru

Zorluk: OrtaReduction of Risk Potential

An assigned client is recovering on the medical-surgical unit two hours after a percutaneous liver biopsy. The client complains of new-onset right shoulder pain. The current vital signs reveal a heart rate of 104 beats/min and a blood pressure of 102/64 mm Hg, compared to a pre-procedure heart rate of 74 beats/min and a blood pressure of 126/80 mm Hg. What is the most appropriate next step for the practical nurse (PN)?

  1. Alert the supervising charge nurse about the assessment changes.Cevap
  2. B
    Provide the prescribed oral analgesic to manage the reported pain.
  3. C
    Help the client transition into a semi-Fowler's resting position.
  4. D
    Document the current assessment and repeat vital signs in sixty minutes.

Cevap

The practical nurse should immediately alert the supervising charge nurse about the assessment changes, as these findings strongly suggest internal bleeding.
The client is demonstrating early signs of hypovolemic shock due to internal hemorrhage, a known complication of a liver biopsy. The decreasing blood pressure and increasing heart rate, combined with right shoulder pain (which indicates referred pain from diaphragmatic irritation due to blood accumulation), require immediate escalation to the supervising nurse or provider for rapid intervention.

Adım Adım Çözüm

1
Analyze the client's vital sign trends.
The heart rate increased from 74 to 104 beats/min, and blood pressure decreased from 126/80 to 102/64 mm Hg.
Comparing current vital signs to the pre-procedure baseline is essential to identify early physiological deterioration.
2
Evaluate the significance of the localized pain.
The client has new-onset right shoulder pain following a liver biopsy.
Blood accumulating in the abdomen can irritate the diaphragm and phrenic nerve, causing referred pain to the right shoulder.
3
Determine the priority nursing intervention.
The priority is to immediately escalate the findings to the supervising RN or healthcare provider.
The combination of borderline vital signs and referred pain indicates active internal hemorrhage, which is a life-threatening complication requiring immediate medical intervention beyond the PN scope of practice.

Anahtar Kavram

Recognizing and escalating early signs of hypovolemic shock (hemorrhage) following invasive procedures.
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Konular

Reduction of Risk Potential

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