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Difficulty: HardPhysiological Adaptation

While providing morning care for an older adult client 48 hours after an open reduction and internal fixation of a fractured right femur, the practical nurse notes a sudden change in status. The client is highly restless, unable to state their location, and has a respiratory rate of 24 breaths/minute with an oxygen saturation of 92% on room air. Furthermore, scattered pinpoint, non-blanching red spots are visible across the client's anterior chest. Which action is the priority for the practical nurse to take?

  1. Elevate the head of the bed, apply supplemental oxygen, and urgently notify the registered nurse.Answer
  2. B
    Assess the pedal pulses, skin temperature, and capillary refill of the right lower extremity.
  3. C
    Obtain a urine specimen to screen for infection and frequently reorient the client to the environment.
  4. D
    Document the current vital signs in the health record and plan to reassess the client's respiratory status in 30 minutes.

Answer

The priority action is to elevate the head of the bed, apply supplemental oxygen, and urgently notify the registered nurse.
The client is exhibiting the classic clinical triad of fat embolism syndrome (hypoxemia, neurologic abnormalities, and a petechial rash), which is a severe medical emergency strongly associated with long bone fractures. The priority action for the practical nurse is to immediately support the client's airway and breathing by applying supplemental oxygen and to escalate the care by notifying the registered nurse or provider for urgent medical intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client presents with hypoxia (SpO2 92%, RR 24), neurological compromise (restlessness, disorientation), and a petechial rash on the chest.
Identifying symptom clusters is essential to determine the underlying pathophysiology.
2
Connect the symptom cluster to the client's medical history.
The triad of hypoxemia, neurological changes, and a petechial rash in a client with a recent long bone (femur) fracture indicates fat embolism syndrome (FES).
Fat embolism syndrome is a specific, life-threatening complication of orthopedic trauma that requires immediate recognition.
3
Determine the priority nursing intervention based on the ABCs (Airway, Breathing, Circulation).
The practical nurse must address the compromised breathing and oxygenation first by applying oxygen and elevating the head of the bed, followed by immediate escalation to the registered nurse.
Systemic life-threatening emergencies must be treated before localized assessments or routine data collection.

Key Concept

Fat Embolism Syndrome Recognition and ABC Prioritization
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Topics

Physiological Adaptation

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