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Difficulty: HardPhysiological Adaptation

During morning rounds on a medical-surgical unit, the practical nurse (PN) assesses a 76-year-old client recovering from a severe gastrointestinal hemorrhage. The client, who was alert and oriented during the previous shift, is now restless, picking at the bedsheets, and speaking incoherently. Current vital signs reveal a blood pressure of 100/58 mm Hg, a heart rate of 114 beats/minute, and a respiratory rate of 24 breaths/minute. Which immediate actions should the PN take? Select all that apply.

  1. Obtain the client's current oxygen saturation level using a pulse oximeter.Answer
  2. Notify the registered nurse immediately regarding the change in mental status and vital signs.Answer
  3. Prepare to administer supplemental oxygen per the emergency protocol.Answer
  4. D
    Document the disorientation as an expected manifestation of environmental change in an older adult.
  5. E
    Continue with routine every-four-hour vital sign checks since the systolic blood pressure remains above 90 mm Hg.
  6. F
    Administer the prescribed as-needed oral analgesic to help alleviate the client's restlessness.

Answer

The correct actions are to obtain the oxygen saturation level, notify the registered nurse immediately, and prepare to administer supplemental oxygen.
The client is exhibiting early signs of hypovolemic shock and decreased cerebral perfusion, likely secondary to the recent gastrointestinal hemorrhage. New-onset restlessness, tachycardia (114 beats/minute), mild tachypnea (24 breaths/minute), and a borderline low blood pressure (100/58 mm Hg) are critical indicators of compensatory shock and hypoxia. The practical nurse must prioritize Airway, Breathing, and Circulation (ABCs) by immediately obtaining an oxygen saturation level and preparing to administer supplemental oxygen. Furthermore, because this represents an acute deterioration in the client's condition, the PN must rapidly notify the registered nurse for further assessment and collaborative intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client has a history of hemorrhage, new-onset restlessness, tachycardia, tachypnea, and borderline hypotension.
Identifying these subtle changes is crucial for recognizing early hypovolemic shock and decreased cerebral perfusion.
2
Prioritize interventions based on the ABCs (Airway, Breathing, Circulation).
Assessing oxygenation (pulse oximetry) and preparing to support perfusion/oxygenation (supplemental oxygen) are prioritized.
In any acute deterioration, securing and supporting the ABCs prevents irreversible end-organ damage.
3
Determine the appropriate scope of practice and communication requirements.
The practical nurse must immediately notify the registered nurse of the acute changes.
Acute instability requires RN assessment, potential provider notification, and collaborative emergency management.

Key Concept

Early recognition of hypovolemic shock and prioritization of ABCs in the acutely deteriorating client.
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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