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Soru

Zorluk: ZorEstablishing Priorities

A nurse has just received the intershift handoff report for a group of clients on an adult acute care unit. Which client must the nurse evaluate first?

  1. A client receiving continuous total parenteral nutrition (TPN) who reports sudden diaphoresis, palpitations, and tremors after the infusion pump was inadvertently turned off 30 minutes ago.Cevap
  2. B
    A client 2 days postoperative following a right total knee arthroplasty who reports a new onset of numbness and a tingling sensation in the right foot.
  3. C
    A client receiving a continuous intravenous heparin infusion for a deep vein thrombosis who has new-onset hematuria and an activated partial thromboplastin time (aPTT) of 95 seconds.
  4. D
    A client with liver cirrhosis and known esophageal varices who had a single episode of dark, tarry stool and has a current blood pressure of 112/74 mm Hg.

Cevap

The client receiving continuous total parenteral nutrition (TPN) who is exhibiting symptoms of severe hypoglycemia following abrupt cessation of the infusion.
The client receiving continuous total parenteral nutrition (TPN) is experiencing acute rebound hypoglycemia. TPN solutions contain high concentrations of dextrose, which stimulates the pancreas to secrete large amounts of endogenous insulin. When the infusion is abruptly halted, insulin levels remain excessively high while the glucose supply is cut off, causing blood glucose to plummet rapidly. Symptoms such as diaphoresis, palpitations, and tremors are immediate sympathetic responses to this severe hypoglycemia. Because the brain relies entirely on glucose for metabolism, this represents an immediate, life-threatening metabolic emergency that takes absolute precedence to prevent seizures, coma, or brain death.

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1
Analyze the clinical presentation of the client receiving TPN.
Identify that abrupt cessation of highly concentrated TPN causes severe rebound hypoglycemia. Symptoms such as diaphoresis, palpitations, and tremors indicate an acute sympathetic nervous system response to critically low blood glucose.
Recognizing metabolic emergencies is critical because the brain requires a continuous glucose supply; profound hypoglycemia can rapidly lead to seizures, coma, and irreversible brain damage.
2
Evaluate the clinical status of the remaining three clients to identify competing priorities.
The client with a knee arthroplasty has signs of a limb-threatening condition (compartment syndrome/neurovascular compromise). The clients with cirrhosis and on heparin have bleeding risks but lack signs of acute hemodynamic instability (shock).
Comparing acuity levels allows the nurse to apply standard triage and prioritization frameworks.
3
Apply the 'life over limb' and 'acute vs. stable' prioritization principles.
Determine that the systemic life threat (acute hypoglycemia) takes absolute precedence over a localized limb threat (paresthesia) and stable bleeding complications.
Nursing prioritization dictates that immediate threats to life, including airway, breathing, circulation, and critical metabolic derangements, must be addressed first.

Anahtar Kavram

Nursing prioritization utilizing the 'life over limb' principle and recognizing acute, life-threatening metabolic crises such as rebound hypoglycemia.
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Establishing Priorities

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