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Zorluk: OrtaEstablishing Priorities

A registered nurse on a medical-surgical unit is evaluating the current clinical status of assigned clients. Which client requires the most immediate intervention?

  1. A client admitted with acute pyelonephritis who is newly restless and has a blood pressure of 88/54 mmHg.Cevap
  2. B
    A client with an exacerbation of ulcerative colitis who reports having six bloody, diarrheal stools over the past 12 hours.
  3. C
    A client with end-stage liver cirrhosis who exhibits palmar erythema and a moderately distended abdomen.
  4. D
    A client who is 2 days post-laparoscopic cholecystectomy and is requesting an immediate dose of PRN analgesic for surgical site pain.

Cevap

The client with acute pyelonephritis exhibiting restlessness and hypotension requires the most immediate intervention.
The correct answer identifies a client experiencing an acute, life-threatening complication. In a client with a known localized infection (pyelonephritis), the sudden onset of restlessness (indicating decreased cerebral perfusion) and marked hypotension are classic indicators of systemic inflammatory response and septic shock. This represents a severe circulatory emergency, making this client the highest priority.

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1
Analyze each client's clinical presentation to determine whether the findings are expected or unexpected for their current diagnosis.
The client with pyelonephritis has unexpected acute findings; the other clients exhibit expected, chronic, or non-emergent findings.
Prioritization requires a nurse to first identify unexpected, acute deviations from a client's baseline.
2
Apply the Airway, Breathing, Circulation (ABC) framework to the client with unexpected findings to determine the severity of the threat.
The pyelonephritis client's hypotension and restlessness indicate a severe circulatory compromise.
Circulatory emergencies, such as septic shock, are immediately life-threatening and take absolute precedence over chronic conditions and pain management.

Anahtar Kavram

Prioritization using the ABC framework and distinguishing acute, life-threatening complications from chronic or expected findings.
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Konular

Establishing Priorities

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