Examkin

Question

Difficulty: MediumPhysiological Adaptation

While performing afternoon rounds, a practical nurse evaluates an older adult client who underwent an abdominal bowel resection two days ago. The client's current vital signs reveal a heart rate of 114 beats per minute and a blood pressure of 96/64 mm Hg. The client, who was previously fully oriented, is now restless, repeatedly asking where they are, and picking at the bed linens. Which action should the practical nurse take first?

  1. Measure the client's oxygen saturation level and immediately notify the registered nurse.Answer
  2. B
    Reorient the client to the hospital room and ensure the bed alarm is activated.
  3. C
    Administer the prescribed as-needed analgesic to help calm the client.
  4. D
    Document the current vital signs and reassess the client at the next scheduled interval.

Answer

Measure the client's oxygen saturation level and immediately notify the registered nurse.
The correct action prioritizes the collection of critical respiratory data and immediate escalation. A sudden change in mental status accompanied by tachycardia and borderline hypotension strongly suggests hypoxia or early shock. The practical nurse must prioritize Airway, Breathing, and Circulation (ABC) assessments and promptly notify the registered nurse for collaborative management.

Step-by-Step Solution

1
Analyze the clinical cues presented by the client.
The client has tachycardia, borderline hypotension, and a sudden change in mental status including restlessness and confusion.
Identifying abnormal findings is the first step in clinical reasoning.
2
Correlate the clinical cues with potential complications.
These findings are classic early signs of hypoxia or hypovolemic shock, which are life-threatening conditions.
Understanding the physiological meaning of the symptoms determines the urgency of the situation.
3
Determine the priority action within the practical nurse scope of practice.
The priority is to gather targeted respiratory data and escalate the findings to the registered nurse for immediate medical intervention.
Airway, Breathing, and Circulation (ABC) issues take precedence over routine care or symptom management.

Key Concept

Early Recognition of Hypoxia and Shock
Rate this question

Topics

Physiological Adaptation

More questions from this topic