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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is assigned to a 78-year-old client who underwent an open reduction and internal fixation (ORIF) of a right femur fracture 24 hours ago. Which of the following actions by the PN demonstrate appropriate clinical judgment regarding the client's physiological adaptation? Select all that apply.

  1. Report the sudden appearance of a petechial rash on the client's anterior chest to the registered nurse (RN).Answer
  2. Notify the RN if the client reports severe, progressive right leg pain that is unrelieved by the prescribed opioid analgesic.Answer
  3. Escalate a morning hemoglobin level of 7.1 g/dL (71 g/L) to the RN before attempting to ambulate the client.Answer
  4. D
    Attribute new-onset agitation and confusion to expected postoperative cognitive decline and proceed with routine care.
  5. E
    Administer a prescribed oral analgesic for incisional pain before investigating a new resting respiratory rate of 28 breaths/minute.
  6. F
    Defer reporting a sustained heart rate of 115 beats/minute and a blood pressure of 90/60 mm Hg because the client states they feel fine.

Answer

The correct actions include reporting the petechial rash, notifying the RN about unrelenting severe pain, and escalating the critically low hemoglobin level.
The correct actions reflect sound clinical judgment by identifying classic signs of postoperative emergencies. A petechial rash is a hallmark of fat embolism syndrome. Severe pain unresponsive to opioid analgesics is a cardinal sign of acute compartment syndrome. A hemoglobin level of 7.1 g/dL indicates severe anemia and potential hemorrhage, making ambulation unsafe and requiring immediate RN notification for potential intervention.

Step-by-Step Solution

1
Analyze the client's postoperative risk profile.
The client is at high risk for complications such as fat embolism, compartment syndrome, and hemorrhage due to the femur fracture and recent surgery.
Identifying potential complications guides targeted data collection.
2
Evaluate each finding for signs of instability or systemic complications.
Petechiae, severe unrelenting pain, and a hemoglobin of 7.1 g/dL indicate critical physiological derangements.
The PN must differentiate between expected postoperative recovery and acute decompensation.
3
Apply the principles of prioritization.
Immediate escalation to the RN is required for findings involving airway/breathing (tachypnea), circulation (tachycardia, hypotension, low hemoglobin), and limb-threatening conditions (compartment syndrome).
Ensuring patient safety requires reporting critical findings before addressing secondary issues like routine incisional pain.

Key Concept

Recognition and prioritization of life-threatening postoperative complications following long bone fractures.
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Topics

Physiological Adaptation

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