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Difficulty: EasyPhysiological Adaptation

A 78-year-old client is on the surgical unit recovering from a femur repair performed this morning. The client is continuously restless and repeatedly asks the practical nurse about their current location. The latest vital signs show a heart rate of 114 beats per minute and a blood pressure of 94/56 mm Hg. Which action should the nurse take first?

  1. Notify the registered nurse immediately regarding the assessment findings.Answer
  2. B
    Reorient the client to the hospital room and provide a calming environment.
  3. C
    Offer the client a dose of prescribed analgesic to alleviate the restlessness.
  4. D
    Document the vital signs as an expected response following a major procedure.

Answer

The correct action is to notify the registered nurse immediately regarding the assessment findings.
The client is demonstrating early indicators of hypovolemic shock, including tachycardia, hypotension, and altered mental status (restlessness and confusion) due to decreased cerebral blood flow. Because this is an acute, unstable change in physiological status, the priority action within the practical nursing scope of practice is to immediately notify the registered nurse so that advanced assessment and resuscitative measures can begin.

Step-by-Step Solution

1
Analyze the clinical cues provided in the scenario.
The client has tachycardia (114 bpm), hypotension (94/56 mm Hg), restlessness, and new-onset confusion.
Identifying abnormal data is the first step in clinical judgment and recognizing physiological decompensation.
2
Relate the abnormal cues to potential postoperative complications.
These findings collectively indicate decreased cardiac output and poor tissue perfusion, which are early signs of hypovolemic shock or hemorrhage.
Postoperative clients, especially older adults having major orthopedic surgery, are at high risk for fluid volume deficit and bleeding.
3
Determine the priority action within the practical nurse scope of practice.
Escalate the unstable findings to the registered nurse.
Acute physiological deterioration requires immediate RN assessment and potential medical intervention to prevent severe harm.

Key Concept

Early Recognition of Hypovolemic Shock
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Topics

Physiological Adaptation

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