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Question

Difficulty: MediumPhysiological Adaptation

Three hours after a total knee arthroplasty, an older adult client becomes newly confused and asks if it is time to go to work. The client's skin appears pale, and current vital signs are: heart rate 108 beats/min, respiratory rate 22 breaths/min, and blood pressure 104/68 mm Hg. Which action should the practical nurse take first?

  1. Inspect the surgical dressing and drainage device for excessive bleeding.Answer
  2. B
    Reorient the client to the hospital environment and provide verbal reassurance.
  3. C
    Document the findings and recheck the vital signs during the next hourly round.
  4. D
    Administer the prescribed as-needed analgesic to manage post-surgical discomfort.

Answer

Inspect the surgical dressing and drainage device for excessive bleeding.
The client's new onset of confusion, pale skin, and slight tachycardia are early clinical indicators of inadequate tissue perfusion and possible hypovolemic shock, which is a major physiological complication following major orthopedic surgery. The priority action for the practical nurse is to assess the client's circulation by inspecting the surgical site and drainage systems for active hemorrhage.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client presents with new-onset confusion, pale skin, slight tachycardia (108 beats/min), and a borderline low blood pressure.
Identifying abnormal data is the first step in clinical reasoning and recognizing physiological compromise.
2
Correlate the assessment findings with potential postoperative complications.
These findings are early compensatory signs of hypovolemic shock, likely caused by postoperative hemorrhage.
Connecting data to potential physiological adaptations determines the severity and urgency of the situation.
3
Determine the priority nursing action based on the ABCs (Airway, Breathing, Circulation).
The most urgent need is to assess for the source of circulatory compromise by inspecting the surgical site.
Because circulation is compromised, identifying active bleeding is the highest priority before escalating the findings to the RN or provider.

Key Concept

Early recognition of hypovolemic shock involves identifying subtle vital sign changes and altered mental status, requiring immediate assessment for bleeding.
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Topics

Physiological Adaptation

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