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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is reviewing the morning data for four assigned clients on a medical-surgical unit. Which client should the PN evaluate first?

  1. A client admitted overnight following a motor vehicle crash with a pelvic fracture, who has a resting heart rate of 114 bpm and a blood pressure of 106/64 mmHgAnswer
  2. B
    A client recovering from a laparoscopic appendectomy performed yesterday, who reports right shoulder pain rated as 5 on a 0 to 10 scale
  3. C
    An 84-year-old client with a history of vascular dementia who is wandering the hallway and looking for a misplaced purse
  4. D
    A client receiving treatment for essential hypertension who has a morning blood pressure reading of 158/86 mmHg

Answer

The client admitted overnight following a motor vehicle crash with a pelvic fracture, who has a resting heart rate of 114 bpm and a blood pressure of 106/64 mmHg.
The correct answer is the client with a pelvic fracture because a heart rate of 114 bpm and a borderline blood pressure of 106/64 mmHg are early, compensatory signs of hypovolemic shock. Pelvic fractures carry a notoriously high risk of massive internal retroperitoneal bleeding. This client is physiologically unstable and requires immediate evaluation and escalation to the registered nurse (RN).

Step-by-Step Solution

1
Analyze the clinical data for each assigned client to identify acute, life-threatening conditions.
The trauma client exhibits tachycardia (heart rate 114 bpm) and borderline hypotension (106/64 mmHg).
Prioritization requires identifying the most physiologically unstable client first.
2
Apply the ABCs (Airway, Breathing, Circulation) framework.
The trauma client's vital signs indicate a potential circulation compromise (hypovolemia/hemorrhage).
Circulation issues take strict priority over pain management, chronic confusion, or stable hypertension.
3
Compare the urgency of all client presentations.
The potential for massive internal hemorrhage in the pelvic fracture client is the most immediate threat.
Early recognition of shock allows for prompt intervention to prevent irreversible cardiovascular collapse.

Key Concept

Recognizing early signs of hypovolemic shock and applying the ABC prioritization framework.
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Topics

Physiological Adaptation

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