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Difficulty: MediumPhysiological Adaptation

While conducting a scheduled assessment on an older adult client two days after an intestinal resection, the practical nurse observes that the client has become suddenly restless and disoriented. The client's vital signs are a heart rate of 118 beats per minute, a blood pressure of 96/58 mm Hg, and a respiratory rate of 26 breaths per minute. Which interventions should the practical nurse implement? Select all that apply.

  1. Alert the charge registered nurse immediately about the acute changes in mental status and hemodynamicsAnswer
  2. B
    Provide a prescribed PRN anti-anxiety medication to calm the client's sudden agitation
  3. Examine the surgical incision site and any drainage systems for evidence of hemorrhageAnswer
  4. D
    Record the disorientation in the chart as an expected manifestation of the aging process
  5. Verify that the client's airway is clear and initiate supplemental oxygen therapy per facility protocolAnswer
  6. F
    Delay further action and check vital signs at the next shift because the systolic pressure has not dropped below 90 mm Hg

Answer

The correct interventions are to alert the charge registered nurse, examine the surgical site for bleeding, and verify airway patency while preparing to administer oxygen.
The client is exhibiting classic early signs of hypovolemic shock, likely due to postoperative hemorrhage. These signs include unexplained restlessness, tachycardia, tachypnea, and borderline hypotension. The practical nurse must prioritize airway and oxygenation, assess for the source of bleeding at the surgical site, and immediately escalate the situation to the registered nurse for advanced medical orders.

Step-by-Step Solution

1
Analyze the client's new-onset symptoms: restlessness, disorientation, tachycardia, tachypnea, and borderline hypotension.
Identify these as classic compensatory signs of early hypovolemic shock, likely due to internal bleeding following the recent intestinal surgery.
Recognizing early shock is critical because delaying intervention until blood pressure profoundly drops can lead to irreversible organ damage.
2
Determine the appropriate priority nursing interventions within the practical nurse scope of practice.
Select actions that support airway and breathing (oxygen), assess the source of the problem (checking the surgical site), and escalate the critical situation (notifying the registered nurse).
The practical nurse must immediately address life-threatening physiological adaptations before attending to routine tasks or assuming findings are benign.

Key Concept

Early Recognition and Prioritization of Hypovolemic Shock
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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