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Zorluk: OrtaReduction of Risk Potential

An adult client is recovering on the surgical unit 4 hours after a laparoscopic appendectomy. The client becomes increasingly restless and repeatedly asks for water due to severe thirst. The nurse reviews the client's vital sign trends over the past hour:

Parameter1 Hour AgoCurrent
Heart Rate82 bpm110 bpm
Blood Pressure128/72 mm Hg114/86 mm Hg
Respiratory Rate14 breaths/min24 breaths/min
Oxygen Saturation98% on room air96% on room air

Which of the following is the priority nursing action to reduce the risk of further physiological deterioration?

  1. A
    Administer the prescribed as-needed intravenous opioid analgesic to manage postoperative pain
  2. B
    Elevate the head of the bed to a high-Fowler's position to promote optimal lung expansion
  3. C
    Assign the unlicensed assistive personnel (UAP) to obtain another set of vital signs in 15 minutes
  4. Notify the healthcare provider immediately and prepare to administer an intravenous fluid bolusCevap

Cevap

Notify the healthcare provider immediately and prepare to administer an intravenous fluid bolus.
The correct answer directly addresses the underlying life-threatening complication. The client's clinical presentation—narrowing pulse pressure, tachycardia, tachypnea, new-onset restlessness, and severe thirst—indicates the compensatory stage of hypovolemic (hemorrhagic) shock. Prompt medical notification and volume replacement are the highest priorities to reduce the risk of further physiological decompensation.

Adım Adım Çözüm

1
Analyze the vital sign trends to calculate the pulse pressure.
The pulse pressure has narrowed significantly from 56 mm Hg (128 - 72) to 28 mm Hg (114 - 86).
A narrowing pulse pressure is a hallmark early indicator of compensatory shock as the body attempts to maintain cardiac output.
2
Correlate the numerical vital signs with the client's physical assessment findings.
The narrowed pulse pressure combined with tachycardia (110 bpm), tachypnea (24 breaths/min), restlessness, and severe thirst confirms early hypovolemic shock.
Restlessness indicates early cerebral hypoxia, and thirst is a strong physiological compensatory response to fluid volume deficit.
3
Determine the priority nursing intervention based on the clinical deterioration.
The nurse must alert the medical team and prepare for immediate fluid resuscitation.
Hemorrhagic shock is a life-threatening complication that requires immediate medical intervention and intravenous volume replacement to prevent irreversible organ damage.

Anahtar Kavram

Early Recognition and Management of Hypovolemic Shock
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Konular

Reduction of Risk Potential

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