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Difficulty: EasyPhysiological Adaptation

A practical nurse is caring for a 78-year-old client who is 12 hours post-operative following abdominal surgery. The client suddenly becomes restless, confused, and has a resting heart rate of 114 beats per minute. Which action should the practical nurse take first?

  1. Measure the client's oxygen saturation and report the findings to the registered nurse.Answer
  2. B
    Ask the client about their current pain level and prepare to administer prescribed analgesics.
  3. C
    Reorient the client to the room and document the new confusion as a standard age-related change.
  4. D
    Continue to monitor the client routinely, as mild tachycardia is an expected finding after surgery.

Answer

Measure the client's oxygen saturation and report the findings to the registered nurse.
Sudden restlessness, confusion, and tachycardia are classic early indicators of hypoxia, hemorrhage, or shock in a post-operative client. The priority action is to assess the client's respiratory status (ABCs) and immediately notify the registered nurse so that prompt medical intervention can be initiated.

Step-by-Step Solution

1
Analyze the client's new symptoms: sudden restlessness, confusion, and tachycardia in a post-operative older adult.
These findings point to an acute physiological change.
Identifying changes from the baseline is the first step in clinical reasoning.
2
Correlate the symptoms with potential post-operative complications.
Restlessness, confusion, and an elevated heart rate are classic early signs of hypoxia or impending shock.
The brain is highly sensitive to decreased oxygen and perfusion, often manifesting as altered mental status before blood pressure significantly drops.
3
Apply the Airway, Breathing, and Circulation (ABC) prioritization framework.
Assessing oxygenation status directly addresses the highest-priority threat to the client's life.
ABC issues always take precedence over comfort measures or routine monitoring.
4
Determine the appropriate action within the practical nursing scope of practice.
The nurse must gather focused data (oxygen saturation) and immediately escalate the acute change to the registered nurse.
Acute physiological decompensation requires rapid intervention and RN/provider collaboration.

Key Concept

Early recognition of hypoxia and shock (ABCs)
Estimated Time:1m 0s
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Topics

Physiological Adaptation

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