Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

A 28-year-old client is being monitored on the medical-surgical unit 4 hours after an open splenectomy following a motor vehicle collision. The nurse compares the current assessment findings with the baseline taken one hour ago:

Baseline (1 hour ago): Blood pressure 126/78 mm Hg, heart rate 88 bpm, respiratory rate 16 breaths/min.
Current: Blood pressure 114/82 mm Hg, heart rate 106 bpm, respiratory rate 22 breaths/min.

The client's urine output for the past hour was 25 mL. Based on these findings, which action should the nurse take first?

  1. Assess the abdominal dressing and incision site for evidence of active bleeding.Cevap
  2. B
    Elevate the head of the bed to a high-Fowler's position to ease respiratory effort.
  3. C
    Administer the prescribed intravenous analgesic to manage anticipated postoperative pain.
  4. D
    Document the vital signs in the electronic health record as expected postsurgical responses.

Cevap

The nurse should first assess the abdominal dressing and incision site for evidence of active bleeding.
The client is exhibiting subtle but classic early signs of hypovolemic (hemorrhagic) shock: a narrowing pulse pressure (48 mm Hg down to 32 mm Hg), mild tachycardia, tachypnea, and decreased urine output. Because the client had major abdominal surgery involving a highly vascular organ, internal or external hemorrhage is a significant risk. Using the nursing process, the nurse must first assess the surgical site and abdomen for signs of bleeding to provide accurate clinical data to the healthcare provider for immediate intervention.

Adım Adım Çözüm

1
Analyze the vital sign trends to identify physiological status.
The client has a narrowing pulse pressure (from 48 to 32 mm Hg), tachycardia, tachypnea, and oliguria (less than 30 mL/hr).
Comparing baseline to current data is essential to detect early physiological decompensation.
2
Correlate the findings with the client's surgical history.
The client is at high risk for hemorrhage following an open splenectomy.
Highly vascular organs like the spleen present a significant risk for postoperative bleeding.
3
Determine the priority nursing action based on the nursing process.
The nurse must gather more specific assessment data about the surgical site before calling the provider or initiating new treatments.
Assessment is the first step of the nursing process; identifying the potential source of bleeding directs subsequent medical and nursing interventions.

Anahtar Kavram

Early recognition of hypovolemic shock and prioritization of nursing assessments
Bu soruyu puanla

Konular

Reduction of Risk Potential

Bu konudan daha fazla soru