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Difficulty: HardPhysiological Adaptation

A client is receiving care in a rehabilitation facility three days after a surgical repair of a fractured femur. The client activates the call light, requesting assistance to use the bedside commode, and mentions feeling unusually weak and slightly dizzy. The practical nurse checks the client's vital signs and notes a heart rate of 114 beats per minute, a respiratory rate of 24 breaths per minute, and a blood pressure of 98/62 mmHg. The client's baseline blood pressure from the previous shift was 138/86 mmHg with a heart rate of 78 beats per minute. Which action is the most appropriate for the practical nurse to take next?

  1. Instruct the client to remain in bed and immediately communicate the assessment findings to the supervising registered nurse.Answer
  2. B
    Assist the client to a sitting position on the edge of the bed and wait five minutes before having them stand.
  3. C
    Palpate the pedal pulses bilaterally and ask the client to rate their current level of operative site pain.
  4. D
    Connect an intravenous infusion of normal saline and set it to a rapid rate to restore the circulating fluid volume.

Answer

The practical nurse should instruct the client to remain in bed and immediately communicate the assessment findings to the supervising registered nurse.
The correct response addresses both client safety and the need for rapid escalation. A significant drop in blood pressure paired with tachycardia in a postoperative client strongly suggests hypovolemia or hemorrhage. By keeping the client in bed, the PN prevents a potential fall and preserves cerebral perfusion, while notifying the RN ensures the client receives prompt medical intervention.

Step-by-Step Solution

1
Analyze the client's current vital signs compared to their baseline data.
The heart rate has increased from 78 to 114 beats per minute, and the blood pressure has dropped from 138/86 to 98/62 mmHg.
Identifying significant deviations from baseline is crucial for recognizing physiological deterioration.
2
Synthesize the vital sign changes with the clinical context (post-femur repair, dizziness, weakness).
The findings point toward hemodynamic instability, such as hypovolemic shock or concealed hemorrhage, rather than benign dizziness.
Orthopedic surgeries carry a high risk for significant blood loss and fluid shifts.
3
Determine the priority action within the practical nursing scope of practice.
The PN must ensure client safety by preventing movement (which could worsen hypotension) and escalate the critical data to the RN.
Acute physiological decompensation requires rapid intervention and falls outside the scope of independent PN management.

Key Concept

Prioritization of care and recognition of hemodynamic instability in postoperative clients.
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Physiological Adaptation

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