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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is caring for an 82-year-old client who is receiving a continuous intravenous heparin infusion for a right leg deep vein thrombosis (DVT). The client suddenly becomes highly restless, reports feeling short of breath, and exhibits a respiratory rate of 28 breaths/min. Which of the following actions should the PN take? (Select all that apply)

  1. Elevate the head of the client's bed.Answer
  2. B
    Administer the prescribed as-needed oral analgesic for leg discomfort.
  3. Notify the registered nurse (RN) immediately.Answer
  4. D
    Inform the family that sudden restlessness is a normal reaction to hospitalization in older adults.
  5. Obtain the client's pulse oximetry reading and complete vital signs.Answer
  6. F
    Document the findings and reassess the respiratory rate in 30 minutes to establish a trend.

Answer

The correct actions are to elevate the head of the client's bed, immediately notify the registered nurse, and obtain the client's pulse oximetry and complete vital signs.
The client is exhibiting signs of acute hypoxia, potentially due to a pulmonary embolism arising from the deep vein thrombosis. Immediate interventions must focus on Airway, Breathing, and Circulation (ABC). Elevating the head of the bed facilitates lung expansion. Obtaining full vital signs provides critical data, and notifying the RN ensures the client receives prompt emergency medical management.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has sudden shortness of breath, tachypnea (28 breaths/min), and new-onset restlessness.
These are hallmark manifestations of a pulmonary embolism, a life-threatening complication of deep vein thrombosis causing acute hypoxia.
2
Determine the priority interventions based on the ABC framework.
Airway and Breathing must be addressed immediately.
Elevating the head of the bed maximizes chest expansion and provides immediate mechanical support for oxygenation.
3
Identify appropriate data collection and escalation protocols.
The PN must obtain full vital signs and escalate the situation to the RN.
The RN must perform an advanced assessment and collaborate with the healthcare provider for emergency medical interventions, while the PN assists by providing critical physiological data.

Key Concept

Prioritization of Airway, Breathing, and Circulation (ABCs) during acute respiratory distress.
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Physiological Adaptation

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