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Difficulty: Very hardPhysiological Adaptation

A 76-year-old client is recovering in the surgical unit 12 hours after a left total hip arthroplasty. The client's admission baseline blood pressure was 154/88 mm Hg with a heart rate of 74 beats/min. Upon entering the room, the practical nurse observes that the client is restless, repeatedly attempting to get out of bed, and unable to state their location. Current vital signs are blood pressure 110/78 mm Hg, heart rate 116 beats/min, and respiratory rate 22 breaths/min. The surgical dressing contains a quarter-sized spot of dark red drainage. What is the priority action for the practical nurse?

  1. A
    Administer the prescribed as-needed analgesic to alleviate the client's restlessness.
  2. B
    Reorient the client to the hospital environment and apply a bed alarm for safety.
  3. C
    Continue routine monitoring because a blood pressure of 110/78 mm Hg is a normal finding.
  4. Immediately report the changes in vital signs and mentation to the registered nurse.Answer

Answer

The priority action is to immediately report the changes in vital signs and mentation to the registered nurse.
The correct answer is to notify the registered nurse because the client is exhibiting classic signs of early compensatory shock. The significant drop in blood pressure from baseline (relative hypotension), tachycardia, and new-onset restlessness indicate poor tissue perfusion. Because the client is hemodynamically unstable, the practical nurse's immediate priority is to escalate the findings so that collaborative, life-saving interventions can begin.

Step-by-Step Solution

1
Analyze the baseline vital signs compared to current vital signs.
The blood pressure has dropped significantly from 154/88 to 110/78 mm Hg, and the heart rate has increased from 74 to 116 beats/min.
Identifying trends is essential to recognize physiological deterioration, as absolute numbers may appear falsely normal.
2
Evaluate the client's new-onset confusion and restlessness.
The acute change in mentation, combined with the vital sign changes, indicates poor cerebral perfusion.
Restlessness and confusion are classic early signs of hypoxia or shock, especially in older adults.
3
Determine the priority practical nursing action based on the findings.
The findings suggest early hypovolemic shock, requiring immediate escalation of care.
The practical nurse must notify the registered nurse when a client becomes unstable to ensure rapid medical intervention and collaborative management.

Key Concept

Early recognition of hypovolemic shock and relative hypotension in older adults
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Physiological Adaptation

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