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Soru

Zorluk: OrtaReduction of Risk Potential

A nurse on a medical-surgical unit has received the shift report for four clients. Which client should the nurse assess first to reduce the risk of a potential life-threatening complication?

  1. A
    A 45-year-old client who underwent a diagnostic lumbar puncture 3 hours ago and is currently resting flat in a supine position
  2. B
    A 55-year-old client with a deep vein thrombosis (DVT) who is reporting a continuous, dull ache in the affected calf
  3. A 68-year-old client who had a thoracentesis 1 hour ago and is exhibiting new-onset restlessness with a heart rate of 118 beats/minCevap
  4. D
    A 72-year-old client with chronic obstructive pulmonary disease (COPD) whose arterial blood gas reveals a pH of 7.35, a PaCO2\text{PaCO}_2 of 52 mm Hg, and an HCO3−\text{HCO}_3^- of 29 mEq/L

Cevap

The client who had a thoracentesis 1 hour ago and is exhibiting new-onset restlessness with a heart rate of 118 beats/min.
The client who recently underwent a thoracentesis is presenting with new-onset restlessness and tachycardia. These are critical early indicators of physiological decompensation, potentially signaling a pneumothorax, internal bleeding, or severe hypoxia. Because this client is exhibiting an acute, unexpected change in respiratory and circulatory status, they represent the highest priority and must be assessed immediately to mitigate life-threatening risks.

Adım Adım Çözüm

1
Analyze the clinical presentation of the client who recently underwent a thoracentesis.
The client is demonstrating new-onset restlessness and a heart rate of 118 beats/min.
Recognizing early physiological signs of decompensation (such as hypoxia or shock) is necessary to catch potential post-procedure complications like a pneumothorax or hemothorax.
2
Evaluate the clinical status and stability of the other three clients.
The client with COPD has fully compensated respiratory acidosis, the lumbar puncture client is in the correct preventative position, and the DVT client has expected localized pain.
Prioritization requires distinguishing between expected, chronic, or stable findings versus acute, unstable changes that threaten the airway, breathing, or circulation.
3
Determine the highest priority client based on the ABCs (Airway, Breathing, Circulation).
The thoracentesis client represents an acute change in breathing and circulation and must be seen immediately.
Acute, unexpected changes post-procedure take precedence over chronic stable findings and expected care routines.

Anahtar Kavram

Prioritization and early recognition of post-procedure complications
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Konular

Reduction of Risk Potential

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