During morning rounds, the practical nurse evaluates an older adult client recovering from a complex pelvic fracture sustained three days ago. The client's family member expresses concern, stating, 'My spouse is acting completely different today and seems very confused.' The nurse notes the client is picking at the bedsheets and appears highly restless. Current vital signs are: temperature 98.8°F (37.1°C), heart rate 112 bpm, respiratory rate 24 breaths/min, blood pressure 106/70 mm Hg, and oxygen saturation 91% on room air. Which actions should the practical nurse implement? (Select all that apply)
- Auscultate bilateral lung fields and apply supplemental oxygen as prescribed.Answer
- BReassure the family that acute disorientation is a routine side effect of prolonged bedrest in older adults.
- Escalate the clinical findings immediately to the supervising registered nurse or healthcare provider.Answer
- DAdminister the prescribed as-needed opioid analgesic to alleviate the client's restlessness and pain.
- EWithhold acute interventions and continue routine monitoring since the systolic blood pressure remains greater than 100 mm Hg.
- Review the client's electronic health record for recent hemoglobin, hematocrit, and arterial blood gas results.Answer
Answer
The correct actions include auscultating the lungs and applying oxygen, notifying the RN or provider immediately, and reviewing recent laboratory results.
The client's sudden onset of confusion, restlessness, tachycardia, tachypnea, and low oxygen saturation in the context of a recent pelvic fracture strongly suggests a life-threatening complication such as fat embolism syndrome or hemorrhage. The practical nurse must prioritize oxygenation (ABCs), immediately escalate the situation to the RN or provider, and gather relevant laboratory data to assist with the ongoing medical evaluation.
Step-by-Step Solution
Key Concept
Recognition and prioritization of acute physiological deterioration in a trauma client.