A practical nurse is caring for an older adult client admitted with a suspected upper gastrointestinal bleed. During data collection, the nurse notes that the client appears increasingly restless and newly confused. The client's vital signs are: blood pressure 104/72 mm Hg, heart rate 112 beats/minute, and respiratory rate 22 breaths/minute. Which of the following actions should the nurse take? Select all that apply.
- Notify the registered nurse (RN) immediately about the changes in mental status and vital signs.Answer
- Apply a pulse oximeter to continuously monitor the client's oxygen saturation levels.Answer
- Verify the patency of the client's established peripheral intravenous (IV) access.Answer
- DAdminister the prescribed oral analgesic to manage the client's reported abdominal discomfort.
- EReassure the family that sudden confusion is an expected reaction to being in a new hospital environment.
- FDocument the heart rate and blood pressure as acceptable baseline findings for an older adult.
Answer
The practical nurse should immediately notify the RN of the changes, apply a pulse oximeter to monitor oxygenation, and verify IV patency for potential emergency fluid administration.
In a client with a gastrointestinal bleed, new-onset restlessness, confusion, and tachycardia are early indicators of hypovolemic shock and decreased cerebral perfusion. The practical nurse must prioritize circulatory and respiratory support by verifying IV patency and monitoring oxygenation, while immediately escalating these critical findings to the RN for further collaborative intervention.
Step-by-Step Solution
Key Concept
Recognition and early intervention for hypovolemic shock