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Difficulty: HardPhysiological Adaptation

During a postoperative check, a practical nurse observes a 28-year-old client recovering from an open reduction and internal fixation of a femur fracture. Six hours after surgery, the client has developed new-onset restlessness and pale, cool skin. Vital signs show a heart rate of 118 bpm, a blood pressure of 102/68 mmHg, and a respiratory rate of 22 breaths/min. The client complains of moderate leg discomfort. Which priority action should the nurse implement?

  1. Report the sudden change in clinical status to the supervising registered nurse.Answer
  2. B
    Provide the scheduled PRN pain medication to address the leg discomfort.
  3. C
    Record the current data in the chart and plan to evaluate again at the next hourly check.
  4. D
    Raise the head of the client's bed to a high-Fowler's position to improve comfort.

Answer

The correct priority action is to report the sudden change in clinical status to the supervising registered nurse.
The correct answer acknowledges that the client is displaying classic early signs of hypovolemic shock, including tachycardia, borderline hypotension, restlessness, and pale, cool skin. In the practical nursing scope of practice, recognizing acute physiological decompensation requires immediate escalation to the registered nurse or provider for advanced assessment and collaborative intervention.

Step-by-Step Solution

1
Analyze the clinical data.
The client has new-onset restlessness, pale/cool skin, tachycardia (118 bpm), and borderline hypotension (102/68 mmHg) following major bone surgery.
Recognizing clustered assessment cues is the first step in clinical judgment.
2
Determine the underlying physiological complication.
These findings collectively indicate early hypovolemic shock, likely due to postoperative internal hemorrhage.
Connecting vital sign trends with physical symptoms helps identify life-threatening conditions.
3
Apply the practical nursing scope of practice and ABC prioritization principles.
The priority is to escalate acute circulatory compromise (Circulation) rather than addressing comfort or implementing routine postoperative tasks.
Airway, breathing, and circulation issues always take precedence over pain management or routine documentation.

Key Concept

Early recognition of hypovolemic shock and acute physiological decompensation
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Topics

Physiological Adaptation

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