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Soru

Zorluk: ZorEstablishing Priorities

During bedside safety checks, a registered nurse gathers the latest assessment data for a group of assigned clients. Which client requires the nurse's immediate attention?

  1. A
    A client with severe chronic obstructive pulmonary disease (COPD) receiving oxygen at 2 L/min who has a PaCO2 of 54 mm Hg and an oxygen saturation of 89%.
  2. A client 6 hours post-laparoscopic appendectomy who is increasingly restless, with a heart rate of 114 beats/min and a blood pressure of 102/82 mm Hg.Cevap
  3. C
    A client with nephrolithiasis who is diaphoretic, pacing the room, and reporting sharp flank pain rated 10 on a 0-10 scale.
  4. D
    A client with a new onset of atrial fibrillation receiving a continuous diltiazem infusion who has an irregular heart rate of 88 beats/min.

Cevap

The client who is 6 hours post-laparoscopic appendectomy with increasing restlessness, tachycardia, and a narrow pulse pressure requires immediate attention.
The post-operative client is exhibiting classic signs of early compensatory hypovolemic shock, likely due to internal hemorrhage. A narrowing pulse pressure (102−82=20102 - 82 = 20 mm Hg), unexplained tachycardia, and restlessness (caused by early cerebral hypoxia) indicate imminent cardiovascular decompensation, making this the absolute highest priority.

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1
Evaluate the client with COPD for acute instability.
The client has a PaCO2 of 54 mm Hg and SpO2 of 89%.
Clients with severe COPD rely on a hypoxic drive and chronically retain CO2; these values are expected baselines and do not represent an acute deterioration.
2
Evaluate the post-operative appendectomy client for signs of complication.
The client is restless, tachycardic (114 beats/min), and has a narrow pulse pressure (102−82=20102 - 82 = 20 mm Hg).
Restlessness (early cerebral hypoxia) combined with tachycardia and a narrow pulse pressure are hallmark indicators of early compensatory hypovolemic shock, likely due to internal hemorrhage.
3
Evaluate the client with nephrolithiasis for immediate risk.
The client reports 10/10 pain and is diaphoretic.
Although the client is in severe distress, pain management falls below airway, breathing, and circulation (ABCs) in prioritization frameworks. This is an expected finding.
4
Evaluate the client with atrial fibrillation on a diltiazem infusion.
The client has an irregular heart rate of 88 beats/min.
The rate is well-controlled (under 100 beats/min), indicating the continuous infusion is achieving its therapeutic goal. The client is hemodynamically stable.
5
Compare all clients to determine the highest priority.
The post-operative client is the only one experiencing a life-threatening, unexpected physiological crisis.
Compensatory shock will rapidly progress to uncompensated circulatory collapse if not immediately identified and treated.

Anahtar Kavram

Recognizing early signs of hypovolemic shock (narrowing pulse pressure, tachycardia, and restlessness) is critical for prioritizing acute post-operative client care over expected chronic findings or severe pain.
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Establishing Priorities

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