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Zorluk: KolayPhysiological Adaptation

Following an abdominal hysterectomy, a client is transferred to the surgical unit. During the initial data collection, the practical nurse notes a heart rate of 114 beats/min and a blood pressure of 94/58 mm Hg. The client states, 'I feel a little nauseous and my incision hurts.' Which action should the nurse take first?

  1. Notify the registered nurse about the current vital signs.Cevap
  2. B
    Administer the prescribed as-needed analgesic for incisional pain.
  3. C
    Document the vital signs as a normal expected postoperative finding.
  4. D
    Assist the client into a high Fowler's position to ease nausea.

Cevap

The correct action is to notify the registered nurse about the current vital signs.
The client is exhibiting tachycardia and borderline hypotension, which are early physiological adaptations to fluid volume deficit or hemorrhage following surgery. Within the practical nursing scope of practice, recognizing these signs of potential shock requires immediate escalation to the registered nurse for further assessment and intervention.

Adım Adım Çözüm

1
Evaluate the client's vital signs and postoperative status.
The heart rate of 114 beats/min and blood pressure of 94/58 mm Hg are identified as abnormal deviations from expected postoperative parameters.
Tachycardia and mild hypotension are early physiological adaptations signaling potential hypovolemia or hemorrhage.
2
Prioritize nursing care based on the ABC (Airway, Breathing, Circulation) framework.
Circulatory stability is prioritized over the client's reports of pain and nausea.
Addressing potential shock takes clinical precedence over general comfort measures.
3
Determine the safest action within the practical nursing scope of practice.
The abnormal findings are immediately reported to the registered nurse.
The practical nurse must escalate signs of acute instability to ensure prompt medical or advanced nursing intervention.

Anahtar Kavram

Recognizing Early Signs of Shock
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Konular

Physiological Adaptation

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