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Difficulty: MediumPhysiological Adaptation

A 78-year-old client is admitted to the medical unit with a history of melena and fatigue. While collecting vital signs, the practical nurse notes a resting heart rate of 112 beats per minute, a blood pressure of 96/62 mm Hg, and acute disorientation to the current location. Which of the following actions should the nurse implement? Select all that apply.

  1. Notify the registered nurse immediately regarding the change in status.Answer
  2. Ensure the patency of the client's peripheral intravenous access.Answer
  3. Apply supplemental oxygen per the facility's standing emergency protocol.Answer
  4. D
    Give the as-needed oral analgesic ordered for mild stomach cramping.
  5. E
    Record the disorientation as a standard expected finding associated with advanced age.
  6. F
    Continue routine monitoring and wait to report the findings until the systolic blood pressure drops below 90 mm Hg.

Answer

The nurse should immediately notify the registered nurse, ensure the patency of the intravenous access, and apply supplemental oxygen.
The client is demonstrating classic signs of compensatory hypovolemic shock and resulting cerebral hypoxia, indicated by tachycardia, borderline low blood pressure, and acute confusion. The practical nurse must prioritize circulation and oxygenation by securing intravenous access, providing supplemental oxygen, and immediately escalating the situation to the registered nurse for advanced intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The combination of tachycardia, borderline low blood pressure, and acute confusion in a client with melena indicates early hypovolemic shock and hypoxia.
Recognizing physiological deterioration is the first step in prioritizing appropriate nursing care.
2
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
Applying supplemental oxygen addresses breathing, while securing IV access and notifying the RN addresses circulation and necessary medical escalation.
Life-threatening physiological issues must be managed before routine or secondary tasks.
3
Identify inappropriate actions that would delay care.
Withholding notification for a lower blood pressure, assuming confusion is age-related, and prioritizing oral pain medication must be avoided.
These actions dangerously misinterpret subtle signs of shock and ignore immediate ABC priorities.

Key Concept

Early Recognition and Management of Hypovolemic Shock
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Topics

Physiological Adaptation

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