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Difficulty: MediumPhysiological Adaptation

A 68-year-old client is on bed rest in skeletal traction after suffering a fractured femur. During mid-afternoon rounding, the client appears anxious, shifts frequently in bed, and expresses intense thirst. Vital signs collected at this time show a heart rate of 112 beats/min, blood pressure of 102/66 mm Hg, and a respiratory rate of 24 breaths/min. The baseline vitals taken upon arrival were a heart rate of 82 beats/min, blood pressure of 130/76 mm Hg, and a respiratory rate of 16 breaths/min. Which action should the practical nurse prioritize?

  1. Communicate the assessment findings to the supervising registered nurse.Answer
  2. B
    Administer the prescribed as-needed opioid analgesic to promote relaxation.
  3. C
    Provide a small cup of water and repeat the vital sign measurements in one hour.
  4. D
    Initiate delirium monitoring and gently reorient the client to the current setting.

Answer

Communicate the assessment findings to the supervising registered nurse.
The correct answer demonstrates an understanding of early shock recognition. Tachycardia, tachypnea, narrowing pulse pressure, restlessness, and thirst are classic early signs of hypovolemia, particularly dangerous in a client with a femur fracture capable of concealing massive internal bleeding. The practical nurse must immediately escalate these findings to the registered nurse for rapid medical intervention.

Step-by-Step Solution

1
Analyze the client's current assessment data compared to baseline.
The client has developed tachycardia, tachypnea, hypotension, anxiety, and thirst.
Identifying trends in vital signs is essential for recognizing physiological deterioration.
2
Correlate the findings with the client's diagnosis and risk factors.
A fractured femur carries a high risk for significant internal bleeding and subsequent hypovolemic shock.
Understanding the clinical context helps interpret the meaning of borderline or changing vital signs.
3
Determine the most appropriate intervention within the practical nurse's scope of practice.
The priority is to report these critical changes to the registered nurse immediately for advanced assessment and intervention.
Early recognition and rapid escalation of care are critical to prevent severe complications of shock.

Key Concept

Early recognition of hypovolemic shock and prioritization of circulatory compromise
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Topics

Physiological Adaptation

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