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Zorluk: OrtaReduction of Risk Potential

A practical nurse (PN) is reviewing morning laboratory data and assessing assigned clients. Which of the following clinical findings indicate a risk for potential complications and require immediate escalation to the registered nurse? (Select all that apply)

  1. A client who had abdominal surgery 4 hours ago with a resting heart rate of 112 beats/min and a blood pressure of 96/60 mm Hg.Cevap
  2. A client receiving daily furosemide whose morning serum potassium level is 3.1 mEq/L (3.1 mmol/L).Cevap
  3. C
    A client who underwent a total knee arthroplasty 2 days ago reporting incisional pain rated as a 5 on a 0 to 10 numeric scale.
  4. A client who had a thoracentesis 1 hour ago reporting sudden, sharp chest pain and new-onset tachypnea.Cevap
  5. E
    A client prescribed an oral beta-blocker whose resting heart rate is 66 beats/min and blood pressure is 114/72 mm Hg.
  6. A client scheduled for a contrast-enhanced computed tomography (CT) scan whose morning serum creatinine level is 2.4 mg/dL (212 µmol/L).Cevap

Cevap

The findings requiring immediate escalation include the postoperative client with tachycardia and borderline hypotension, the client with a potassium level of 3.1 mEq/L, the post-thoracentesis client with sudden chest pain, and the client scheduled for a contrast CT scan with an elevated creatinine level.
The correct findings all represent acute safety risks that fall outside expected parameters. A heart rate of 112 beats/min with a blood pressure of 96/60 mm Hg in a postoperative client indicates early hypovolemic shock or hemorrhage. A potassium level of 3.1 mEq/L is critically low (normal 3.5-5.0 mEq/L) and risks life-threatening arrhythmias, especially with loop diuretic use. Sudden chest pain and tachypnea after a thoracentesis are classic signs of a pneumothorax. An elevated creatinine level (normal 0.6-1.2 mg/dL) indicates renal impairment, placing the client at high risk for acute kidney injury if intravenous contrast dye is administered.

Adım Adım Çözüm

1
Analyze each client finding to differentiate between expected baseline outcomes and signs of physiological instability.
Identified that post-surgical pain and stable vital signs on a beta-blocker are expected, benign findings.
Prioritization requires distinguishing normal therapeutic responses from acute threats.
2
Evaluate the laboratory values against normal reference ranges.
Identified that a potassium level of 3.1 mEq/L is critically low and a creatinine level of 2.4 mg/dL is abnormally high.
Recognizing critical laboratory values prevents adverse events such as dysrhythmias and nephrotoxicity.
3
Assess the post-procedure findings for signs of life-threatening complications.
Recognized that tachycardia/hypotension post-abdominal surgery indicates shock, and sudden chest pain post-thoracentesis indicates a pneumothorax.
Early recognition of shock and organ compromise allows for rapid medical intervention and prevents mortality.

Anahtar Kavram

Reduction of Risk Potential: Early Recognition of Complications and Critical Labs
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Konular

Reduction of Risk Potential

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