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Difficulty: MediumPhysiological Adaptation

After receiving the shift handoff report for four assigned clients on a step-down medical unit, which client should the practical nurse (PN) evaluate first?

  1. A client who had a femoral cardiac catheterization 4 hours ago, with a heart rate of 114 bpm, blood pressure of 96/60 mm Hg, and new-onset lower back ache.Answer
  2. B
    A client who underwent an open reduction and internal fixation of the ankle 48 hours ago, requesting medication for pain rated as 7 out of 10.
  3. C
    An older adult client with advanced dementia who is pacing the room and repeatedly asking for their spouse.
  4. D
    A client with severe chronic obstructive pulmonary disease (COPD) who has a resting oxygen saturation of 91% on room air.

Answer

The client who had a femoral cardiac catheterization and is exhibiting early signs of shock.
The correct answer is the client recovering from a femoral cardiac catheterization. This client is displaying tachycardia, borderline hypotension, and new-onset back pain, which are classic early signs of a retroperitoneal hemorrhage following a femoral arterial puncture. This represents an acute, life-threatening circulatory compromise (Circulation in ABCs) that requires immediate evaluation and escalation to the registered nurse.

Step-by-Step Solution

1
Analyze the clinical status of the post-cardiac catheterization client.
The combination of tachycardia, low-normal blood pressure, and new back pain suggests a retroperitoneal hemorrhage.
Airway, Breathing, and Circulation (ABCs) take the highest clinical priority; bleeding compromises circulation.
2
Analyze the clinical status of the postoperative ankle client.
Postoperative pain is an expected finding 48 hours after bone surgery.
Pain management is a psychosocial and comfort need that does not supersede acute circulatory failure.
3
Analyze the clinical status of the client with advanced dementia.
Disorientation and pacing are chronic, baseline behaviors for this individual.
Chronic, stable conditions are triaged at a lower priority than acute, newly unstable conditions.
4
Analyze the clinical status of the client with severe COPD.
An oxygen saturation of 91% is an expected baseline adaptation for a client with severe COPD.
Compensated, expected respiratory findings are a lower priority than an uncompensated acute hemorrhage.

Key Concept

Physiological Adaptation (Recognizing early signs of hypovolemic shock and prioritization)
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Topics

Physiological Adaptation

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