Examkin

Question

Difficulty: Very hardPhysiological Adaptation

A client who sustained a complex pelvic fracture in a motor vehicle collision is being monitored on the trauma step-down unit. Four hours after admission, the client is awake, reports pelvic pain rated 5 on a 0-10 scale, and complains of intense thirst. The practical nurse collects the current vital signs: blood pressure 106/80 mm Hg, heart rate 118 beats/min, respiratory rate 22 breaths/min, and a capillary refill time of 4 seconds. The admission blood pressure was 126/74 mm Hg with a heart rate of 86 beats/min. Based on this clinical picture, which action should the practical nurse prioritize?

  1. A
    Record the clinical data in the chart and proceed with the standard monitoring schedule
  2. B
    Increase the rate of the continuous intravenous fluids to stabilize the client's circulatory status
  3. Withhold all oral intake and promptly communicate the assessment findings to the supervising registered nurseAnswer
  4. D
    Provide a small cup of water and give the ordered pain medication to address the client's primary complaint

Answer

The practical nurse must keep the client NPO (nothing by mouth) and immediately escalate the assessment findings to the registered nurse.
The correct answer acknowledges that the client is exhibiting classic signs of early, compensatory hypovolemic shock due to massive internal bleeding commonly associated with pelvic fractures. Intense thirst, tachycardia, a narrowed pulse pressure (the difference between systolic and diastolic pressures), and delayed capillary refill all indicate severe intravascular volume loss. Withholding oral fluids protects the airway if emergency surgery is needed, and immediate escalation is required for lifesaving interventions.

Step-by-Step Solution

1
Analyze the vital sign trends compared to the admission baseline.
The heart rate increased from 86 to 118 bpm, the pulse pressure narrowed significantly (from 52 to 26 mm Hg), and capillary refill is delayed (4 seconds).
Identifying deviations from baseline is critical for recognizing early physiological decompensation.
2
Correlate the vital signs with the client's injury and symptoms.
Pelvic fractures carry a high risk of massive hidden hemorrhage. The combination of tachycardia, narrowed pulse pressure, delayed perfusion, and intense thirst strongly indicates early compensatory shock.
Understanding the underlying pathophysiology of the specific injury guides clinical judgment.
3
Determine the safest and most appropriate scope-compliant intervention.
The priority is to anticipate the need for surgical intervention (requiring NPO status) and alert the RN or provider to initiate aggressive resuscitation.
The practical nurse must recognize life-threatening complications and escalate care while maintaining patient safety.

Key Concept

Recognition of early compensatory shock and internal hemorrhage
Rate this question

Topics

Physiological Adaptation

More questions from this topic