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Zorluk: OrtaEstablishing Priorities

A nurse is reviewing assessment data for a group of assigned clients on a medical-surgical unit. Which of the following client findings require immediate follow-up by the nurse? Select all that apply.

  1. A client with a deep vein thrombosis who develops sudden shortness of breath and diaphoresis.Cevap
  2. A client receiving treatment for sepsis who has a urine output of 15 mL over the past hour.Cevap
  3. C
    A client with chronic obstructive pulmonary disease (COPD) who has a resting oxygen saturation of 91% on room air.
  4. D
    A client who is 12 hours post-laparoscopic cholecystectomy reporting mild abdominal bloating and right shoulder pain.
  5. A client with a recent concussion who exhibits increasing restlessness and repeatedly asks the same questions.Cevap

Cevap

The clients requiring immediate follow-up are the one with sudden shortness of breath, the one with low urine output, and the one with increasing restlessness.
The correct selections represent acute, unstable, or life-threatening conditions. Sudden shortness of breath in a client with a deep vein thrombosis strongly suggests a pulmonary embolism (an airway/breathing emergency). A urine output of 15 mL/hr in a client with sepsis indicates inadequate systemic perfusion and impending shock (a circulation emergency). Increasing restlessness and repetitive questioning in a client with a head injury are early, critical signs of increasing intracranial pressure or decreased cerebral oxygenation.

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1
Evaluate each client's clinical presentation using the Airway, Breathing, and Circulation (ABC) prioritization framework.
Identified that sudden shortness of breath involves airway/breathing, and low urine output in sepsis involves circulation/perfusion.
Conditions threatening the ABCs take highest priority.
2
Assess for acute neurological changes indicating potential deterioration.
Identified that increasing restlessness in a concussion client suggests rising intracranial pressure or hypoxia.
Acute changes in level of consciousness are a top clinical priority requiring rapid intervention.
3
Differentiate between expected disease manifestations (chronic/stable) and unexpected acute alterations.
Determined that the COPD oxygen saturation and post-laparoscopic shoulder pain are expected, non-urgent findings.
Clients with expected, stable findings are categorized as lower priority compared to those with new or worsening acute conditions.

Anahtar Kavram

Clinical Prioritization using ABCs and Acute vs. Chronic Principles
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Konular

Establishing Priorities

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