Examkin

Question

Difficulty: MediumPhysiological Adaptation

An 82-year-old client is 8 hours post-operative following the surgical repair of a fractured femur. During the evening rounds, the practical nurse notes the client has become suddenly restless, slightly confused, and is picking at the bedsheets. Current vital signs are a blood pressure of 106/64 mm Hg, a heart rate of 118 beats/min, and a respiratory rate of 24 breaths/min. The client's baseline preoperative vital signs were a blood pressure of 138/76 mm Hg and a heart rate of 82 beats/min. Which action should the practical nurse take first?

  1. A
    Reorient the client to the environment and document the new onset of confusion as age-related sundowning.
  2. B
    Administer the prescribed as-needed opioid medication, assuming the client's restlessness is caused by uncontrolled surgical pain.
  3. Obtain the client's oxygen saturation, inspect the surgical dressing for active bleeding, and promptly notify the registered nurse.Answer
  4. D
    Record the vital signs as acceptable post-operative findings and dim the room lights to encourage sleep.

Answer

The correct action is to obtain the client's oxygen saturation, inspect the surgical dressing for active bleeding, and promptly notify the registered nurse.
Sudden onset confusion, restlessness, tachycardia, and a downward trend in blood pressure in a post-operative client are hallmark early signs of impaired tissue perfusion. This can be caused by hemorrhage or hypoxia. The practical nurse must prioritize further data collection related to airway, breathing, and circulation (ABC) and immediately report these critical findings to the registered nurse for rapid medical evaluation and intervention.

Step-by-Step Solution

1
Analyze the client's change in mental status.
Sudden restlessness and confusion in a post-operative older adult are recognized as early clinical indicators of hypoxia or impaired cerebral perfusion, rather than expected aging changes.
Identifying acute physiological alterations is the critical first step in clinical judgment.
2
Evaluate the vital sign trends compared to the client's baseline.
The significant drop in blood pressure alongside the increase in heart rate and respiratory rate indicates potential compensatory shock or hemorrhage.
Recognizing borderline but deteriorating vital signs prevents failure to rescue.
3
Determine the priority nursing intervention within the practical nurse scope of practice.
The practical nurse must collect targeted physical data related to oxygenation and circulation, and immediately collaborate with the registered nurse for advanced intervention.
Prioritizing airway, breathing, and circulation (ABC) ensures client safety during acute physiological decompensation.

Key Concept

Early Recognition of Post-Operative Hypovolemia and Hypoxia
Estimated Time:1m 30s
Rate this question

Topics

Physiological Adaptation

More questions from this topic