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Difficulty: MediumPhysiological Adaptation

An 80-year-old client is admitted to the medical-surgical unit with an acute gastrointestinal hemorrhage. The client has a peripheral intravenous line infusing 0.9% sodium chloride. Which actions by the practical nurse demonstrate safe and effective prioritization of the client's physiological adaptation? Select all that apply.

  1. Elevating the head of the bed and verifying airway patency if the client begins vomiting active red blood.Answer
  2. Notifying the registered nurse immediately when the client's resting heart rate increases to 112 beats/min with a blood pressure of 100/64 mm Hg.Answer
  3. Applying a pulse oximeter to check oxygen saturation when the client becomes newly restless and diaphoretic.Answer
  4. D
    Administering a scheduled oral analgesic for chronic joint pain before assessing a new onset of rapid, shallow breathing.
  5. E
    Instructing the family that the client's sudden disorientation to person and place is a normal consequence of advanced age.
  6. F
    Continuing routine hourly observations without reporting a newly documented blood pressure of 96/60 mm Hg because the client is resting quietly.

Answer

The correct actions include elevating the head of the bed during vomiting, notifying the registered nurse of early shock vitals, and checking oxygen saturation for sudden restlessness.
The correct actions focus on maintaining airway patency during emesis, promptly recognizing and reporting early compensatory signs of hypovolemic shock (tachycardia, borderline hypotension), and assessing for hypoxia when neurological changes occur. These interventions align with the practical nurse's scope of practice for prioritizing physiological safety.

Step-by-Step Solution

1
Analyze the client's clinical condition and associated risks.
The client has a gastrointestinal hemorrhage, placing them at high risk for hypovolemic shock, airway compromise (from vomiting blood), and hypoxia.
Understanding the primary diagnosis helps the nurse anticipate potential life-threatening physiological complications.
2
Evaluate each nursing action against the ABC (Airway, Breathing, Circulation) priority framework.
Elevating the bed protects the airway; checking oxygenation prioritizes breathing; reporting tachycardia and borderline hypotension addresses circulation.
The ABC framework dictates the immediate survival priorities in acute physiological adaptation scenarios.
3
Differentiate expected baseline gerontological findings from signs of acute physiological deterioration.
Sudden confusion is an acute change indicating hypoxia or shock, not normal aging. Borderline low blood pressure is an early warning sign of hemorrhage, not an expected stable finding.
Failing to recognize subtle changes delays life-saving interventions and compromises client safety.

Key Concept

Prioritization of care and recognition of early signs of hypovolemic shock in a bleeding client.
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Physiological Adaptation

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