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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is assigned to a 78-year-old client who sustained a fractured right femur 24 hours ago. The client, who has a history of mild cognitive impairment, suddenly becomes highly agitated, attempts to pull out the intravenous (IV) line, and develops a respiratory rate of 28 breaths/minute with newly noted petechiae on the upper chest. Which actions should the PN take? Select all that apply.

  1. Apply a pulse oximeter to measure the client's oxygen saturation.Answer
  2. Request immediate assistance from the registered nurse (RN) to evaluate the client.Answer
  3. Elevate the head of the client's bed to a semi-Fowler's or high-Fowler's position.Answer
  4. D
    Reassure the client and dim the room lights to manage the cognitive impairment.
  5. E
    Administer the client's prescribed as-needed (PRN) oral opioid analgesic for potential fracture pain.
  6. F
    Record the respiratory rate as borderline high and continue monitoring during the next scheduled shift round.

Answer

The practical nurse should apply a pulse oximeter, request immediate assistance from the registered nurse, and elevate the head of the bed.
The client's presentation of sudden agitation, tachypnea, and a petechial rash on the upper chest 24 hours after a femur fracture is the classic triad of fat embolism syndrome. This is a medical emergency causing severe hypoxia. The practical nurse must immediately address the client's respiratory status (Breathing) by elevating the head of the bed to facilitate lung expansion, applying a pulse oximeter to gather objective data on oxygenation, and urgently notifying the registered nurse to coordinate emergency interventions.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a long bone fracture and suddenly presents with acute agitation, tachypnea (28 breaths/min), and chest petechiae.
Identifying these specific cues is necessary to recognize fat embolism syndrome, a life-threatening complication of long bone fractures.
2
Determine the highest priority of care based on the ABC (Airway, Breathing, Circulation) framework.
The client is exhibiting signs of severe respiratory compromise (Breathing) and acute hypoxia.
Prioritizing ABCs ensures that life-threatening conditions are addressed first.
3
Select the nursing actions that immediately address the physiological crisis within the PN scope of practice.
Elevating the head of the bed, measuring oxygen saturation, and escalating to the RN are immediate, scope-appropriate actions.
The PN must gather critical respiratory data, position the client to maximize oxygenation, and involve the RN for advanced assessment and collaborative care.

Key Concept

Recognition and immediate management of fat embolism syndrome in clients with long bone fractures, prioritizing airway and breathing.
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Topics

Physiological Adaptation

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