Recognition Of Potential Complications - NCLEX-PN

Platelet count drop with new thrombosis. HIT involves antibody-mediated platelet destruction and activation, paradoxically causing thrombocytopenia alongside new clot formation.

Gastrointestinal bleeding. Warfarin anticoagulation increases bleeding risk, with melena indicating upper GI hemorrhage from altered clotting.

Coarse tremor and ataxia. Lithium toxicity impairs neurologic function, producing gross motor disturbances like tremor and ataxia that necessitate immediate intervention.

Bradycardia with nausea and visual halos. Digoxin toxicity affects the heart and nervous system, causing slowed heart rate, gastrointestinal upset, and visual disturbances like halos.

Kussmaul respirations with fruity breath odor. DKA involves metabolic acidosis prompting deep, rapid breathing for compensation and ketosis producing a characteristic fruity acetone odor.

Diaphoresis with shakiness and confusion. Hypoglycemia triggers adrenergic responses like sweating and tremors, alongside neuroglycopenic effects causing confusion.

Wheezing or stridor with hypotension. Anaphylaxis involves bronchoconstriction causing wheezing or stridor and systemic vasodilation leading to hypotension as part of a severe allergic response.

Sudden dyspnea with pleuritic chest pain. Pulmonary embolism often presents with abrupt shortness of breath and chest pain worsened by inspiration due to vascular occlusion in the lungs.

Deep vein thrombosis (DVT). Sudden unilateral leg symptoms suggest venous thrombosis obstructing blood flow, leading to swelling and pain in the affected limb.

Restlessness or new-onset confusion. Hypoxia initially impairs cerebral function, manifesting as behavioral changes like restlessness or confusion before more severe symptoms develop.

Tachycardia with hypotension and cool, clammy skin. These signs reflect compensatory tachycardia from volume loss, reduced perfusion causing hypotension, and vasoconstriction leading to cool, clammy skin in hypovolemic shock.

Acute airway obstruction. Stridor indicates upper airway narrowing, while drooling suggests inability to swallow secretions, often from epiglottitis or foreign body in children.

Unilateral facial droop with arm drift. Focal neurologic deficits like hemiparesis distinguish stroke from diffuse metabolic issues like hypoglycemia, which lack laterality.

Acute coronary syndrome (myocardial infarction). Persistent chest pain with sympathetic activation like sweating suggests myocardial ischemia or infarction requiring urgent evaluation.

Suprapubic distention with inability to void. Urinary retention leads to bladder overdistention, palpable suprapubically, with failure to empty despite the urge or effort.

New cough with crackles and oxygen desaturation. Aspiration introduces feedings into the lungs, causing inflammation that manifests as cough, adventitious sounds, and impaired gas exchange.

Paralytic ileus. Postoperative ileus causes temporary paralysis of intestinal motility, resulting in absent bowel sounds and gaseous distention.

Sudden serosanguineous drainage from incision. A sudden gush of serosanguineous fluid signals separation of wound edges, increasing risk for evisceration if not addressed promptly.

Increasing drainage with falling blood pressure. Increased drainage suggests ongoing blood loss, while hypotension reflects hypovolemia from hemorrhage in the postoperative period.

Hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to cramps and carpopedal spasm elicited by Trousseau sign.

Hemorrhage. Bright red hematuria with clots post-TURP indicates active bleeding from the surgical site in the prostate or bladder.

New unequal pupils (anisocoria). Unequal pupils indicate potential brain herniation or focal lesions compressing the oculomotor nerve, signaling urgent neurologic compromise.

Peaked T waves. Elevated potassium alters cardiac repolarization, producing tall, peaked T waves on ECG as an early indicator of hyperkalemia.

Decreasing level of consciousness. Rising ICP compresses brain tissue, progressively impairing arousal and awareness, making altered consciousness a hallmark sign.