During the afternoon shift, an 82-year-old client recovering from a total hip arthroplasty three days ago becomes acutely restless and repeatedly attempts to climb over the bed rails. The client was previously oriented but is now calling out for a deceased spouse. Current vital signs reveal a heart rate of 108 beats/minute, blood pressure of 106/64 mm Hg, and respiratory rate of 24 breaths/minute. Which action should the practical nurse prioritize?
- AConsult the family members to determine if there is a baseline history of dementia
- BDocument the vital signs as stable and continue with routine postoperative monitoring
- Obtain a peripheral pulse oximetry reading to evaluate for potential systemic hypoxiaAnswer
- DReorient the client to the hospital environment and immediately implement strict fall precautions
Answer
The nurse should prioritize obtaining a peripheral pulse oximetry reading to evaluate for potential systemic hypoxia.
Sudden onset of confusion, restlessness, and tachypnea in a postoperative client strongly suggests a physiological complication such as hypoxia, pulmonary embolism, or early shock. The nurse must first prioritize airway and breathing (ABCs) by assessing oxygen saturation before addressing behavioral symptoms.
Step-by-Step Solution
Key Concept
Prioritizing ABCs and recognizing hypoxia as a primary cause of acute confusion in older adults.