Examkin

Question

Difficulty: HardPhysiological Adaptation

A 78-year-old client is recovering on the surgical unit 48 hours after a bowel resection. The practical nurse enters the room and finds the client restless and newly disoriented to place. The client's family member states, "I think the surgical pain is just keeping him awake." The client's current vital signs are a heart rate of 114 beats/min, a blood pressure of 96/54 mm Hg, and a respiratory rate of 22 breaths/min. Which action should the practical nurse prioritize?

  1. A
    Administer the prescribed as-needed analgesic to address the client's discomfort.
  2. B
    Record the vital signs as acceptable postoperative findings and monitor closely.
  3. Notify the registered nurse immediately to report the changes in condition.Answer
  4. D
    Reassure the family that postoperative confusion is a normal expectation for an older adult.

Answer

Notify the registered nurse immediately to report the changes in condition.
The correct action identifies the urgent need for clinical escalation. The client's new-onset disorientation, restlessness, tachycardia (114 beats/min), and mild hypotension (96/54 mm Hg) represent a cluster of subtle, early signs of acute decompensation, such as hypovolemic or septic shock. Within the practical nurse scope of practice, recognizing this physiological instability requires immediately notifying the registered nurse so that rapid, collaborative interventions can be initiated to restore adequate tissue perfusion.

Step-by-Step Solution

1
Analyze the clinical data presented in the scenario.
A 78-year-old postoperative client has new-onset restlessness, disorientation, tachycardia (114 beats/min), and mild hypotension (96/54 mm Hg).
Identifying all abnormal findings is the first step in data collection.
2
Interpret the clinical significance of the findings.
While the family suspects pain, the cluster of altered mental status and borderline hemodynamics strongly suggests poor tissue perfusion and the early stages of shock.
Distinguishing between expected postoperative discomfort and life-threatening physiological adaptation is crucial for client safety.
3
Determine the priority nursing action based on scope of practice.
The practical nurse must immediately escalate the situation to the registered nurse.
Acute, unstable physiological changes require comprehensive assessment and rapid collaborative intervention beyond the practical nurse's independent scope.

Key Concept

Early Recognition of Hemodynamic Instability and Shock
Estimated Time:1m 30s
Rate this question

Topics

Physiological Adaptation

More questions from this topic