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Soru

Zorluk: ZorEstablishing Priorities

The charge nurse on a medical-surgical step-down unit is evaluating the clinical status of four assigned clients. Which client requires the most immediate assessment by the nurse?

  1. A client admitted with acute pancreatitis whose latest vital signs demonstrate a blood pressure of 106/88 mm Hg and a heart rate of 118 beats/minuteCevap
  2. B
    A client with severe chronic obstructive pulmonary disease (COPD) whose morning arterial blood gas reveals a pH of 7.34, PaCO2 of 58 mm Hg, and HCO3 of 32 mEq/L
  3. C
    A client receiving continuous intravenous heparin for a deep vein thrombosis whose most recent activated partial thromboplastin time (aPTT) is 78 seconds
  4. D
    A client 2 days post-operative from an open bowel resection who reports intermittent, cramping abdominal pain and has not yet had a bowel movement

Cevap

The client with acute pancreatitis demonstrating a blood pressure of 106/88 mm Hg and a heart rate of 118 beats/minute.
The correct answer identifies the client exhibiting a narrowing pulse pressure (106 - 88 = 18 mm Hg) and tachycardia (118 bpm). In the context of acute pancreatitis, massive fluid shifts from the intravascular space into the retroperitoneal cavity (third-spacing) frequently occur. A narrowed pulse pressure paired with a rising heart rate is a classic physiological hallmark of early hypovolemic shock due to decreased stroke volume and compensatory sympathetic nervous system activation. This client requires immediate fluid resuscitation and assessment to prevent cardiovascular collapse.

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1
Analyze the vital signs of the client with acute pancreatitis.
The pulse pressure is exceptionally narrow at 18 mm Hg (106 - 88) and the heart rate is tachycardic at 118 bpm.
To identify subtle signs of physiological deterioration, such as compensatory mechanisms for early shock.
2
Evaluate the ABG results for the client with COPD.
The ABG demonstrates compensated chronic respiratory acidosis (pH 7.34, PaCO2 58, HCO3 32).
To differentiate between an acute respiratory failure crisis and an expected, chronic physiological baseline.
3
Review the laboratory values for the client on continuous heparin therapy.
The aPTT of 78 seconds safely falls within the expected therapeutic range.
To determine if the client is at an acute risk for hemorrhage or clotting.
4
Compare the acuity of all four clients using the prioritization framework (acute vs. chronic, unexpected vs. expected).
The client with pancreatitis exhibits unexpected, acute signs of early hypovolemic shock (third-spacing). The other three clients exhibit expected, stable findings for their respective conditions.
To identify the single client experiencing the most immediate life-threatening condition.

Anahtar Kavram

Prioritization requires identifying acute, unexpected systemic deterioration (such as early signs of shock) over chronic, compensated, or expected postoperative findings.
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Establishing Priorities

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