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Difficulty: HardPhysiological Adaptation

An older adult client is receiving treatment for a small bowel obstruction and has a nasogastric tube set to low continuous suction. Over the past six hours, the tube has drained 750 mL of gastric fluid. The assistive personnel reports that the client, who was previously alert and cooperative, is now persistently asking questions about a workplace they retired from two decades ago. The practical nurse enters the room and notes the client has a resting heart rate of 114 beats/min. Which action should the practical nurse take first?

  1. Assess the client's blood pressure and alert the supervising registered nurse about the clinical changes.Answer
  2. B
    Utilize therapeutic communication techniques to orient the client to the current time and place.
  3. C
    Auscultate all four abdominal quadrants to evaluate for the return of normal bowel activity.
  4. D
    Continue routine monitoring of the heart rate and record the total drainage volume in the chart.

Answer

The practical nurse should prioritize assessing the client's blood pressure and alerting the supervising registered nurse about the clinical changes.
The correct action prioritizes the identification and management of a potential circulatory collapse. The client has experienced significant fluid loss via the nasogastric tube. The new onset of confusion indicates impaired cerebral perfusion, while the heart rate of 114 beats/min is a compensatory mechanism attempting to maintain cardiac output. This combination strongly suggests early hypovolemic shock. The practical nurse must immediately obtain the blood pressure to fully assess hemodynamic stability and alert the supervising nurse so that emergency fluid resuscitation can be initiated.

Step-by-Step Solution

1
Analyze the collective clinical data: 750 mL of gastric output, new-onset confusion, and unexplained tachycardia.
Identifies a pattern of significant fluid loss leading to potential hypoperfusion.
Large volumes of gastrointestinal drainage rapidly cause isotonic fluid volume deficit (hypovolemia) and electrolyte imbalances.
2
Determine the physiological cause of the sudden symptom onset.
Recognizes that the altered mental status and rising heart rate are early compensatory mechanisms for hypovolemic shock.
Decreased circulating blood volume reduces cerebral perfusion (causing confusion) and triggers the sympathetic nervous system to increase the heart rate in an attempt to maintain cardiac output.
3
Select the priority intervention based on the practical nurse scope of practice.
Prioritizes gathering complete hemodynamic data (blood pressure) and immediately escalating the care to the registered nurse.
Recognizing acute circulatory instability requires prompt reporting to facilitate immediate fluid resuscitation and prevent severe organ damage.

Key Concept

Hypovolemic Shock Recognition and Escalation
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Topics

Physiological Adaptation

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