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Difficulty: MediumPhysiological Adaptation

Following a right knee arthroplasty, a 74-year-old client is admitted to the orthopedic unit. The client's baseline mental status was alert and oriented. During a routine check, the practical nurse finds the client newly confused and persistently attempting to get out of bed. The client's heart rate is 118 beats/min, respiratory rate is 24 breaths/min, and blood pressure is 106/58 mm Hg. The closed-suction drain has accumulated 260 mL of bright red fluid within the last hour. Which action should the nurse prioritize?

  1. Alert the registered nurse immediately regarding the change in condition and increased drainageAnswer
  2. B
    Implement fall precautions and recognize the confusion as a common age-related postoperative reaction
  3. C
    Document the data and plan to reassess in one hour, since the systolic blood pressure remains greater than 100 mm Hg
  4. D
    Administer the prescribed as-needed pain medication to treat the underlying cause of the agitation

Answer

The priority action is to alert the registered nurse immediately regarding the change in condition and increased drainage.
The client is displaying early signs of hypovolemic shock due to significant postoperative hemorrhage, evidenced by 260 mL of bright red drainage in a single hour. Tachycardia, tachypnea, and sudden confusion (due to decreased cerebral perfusion) are compensatory mechanisms indicating compromised circulation. The absolute priority for the practical nurse is escalating this unstable condition to the registered nurse for immediate medical intervention.

Step-by-Step Solution

1
Analyze the client's assessment data.
Identifies 260 mL of bright red drainage in one hour, accompanied by tachycardia, tachypnea, and new-onset confusion.
To determine the physiological significance of the physical findings and vital signs.
2
Correlate the clinical picture with potential postoperative complications.
Recognizes a pattern indicating acute blood loss and early compensatory hypovolemic shock.
To differentiate between expected postoperative recovery and a life-threatening emergency.
3
Determine the priority nursing intervention based on scope of practice.
Selects immediate escalation to the registered nurse for collaborative emergency management.
Hemodynamic instability requires immediate medical and RN intervention outside the independent scope of a practical nurse.

Key Concept

Hypovolemic Shock Recognition and Prioritization
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Topics

Physiological Adaptation

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