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Difficulty: MediumPhysiological Adaptation

An unlicensed assistive personnel (UAP) informs the practical nurse (PN) that a 77-year-old client is suddenly agitated and disoriented. The client had a surgical repair of a fractured femur 24 hours ago. Upon assessment, the PN notes the client has a respiratory rate of 26 breaths/minute, a heart rate of 109 beats/minute, and a blood pressure of 102/64 mm Hg. Which of the following actions should the PN take? Select all that apply.

  1. Apply a pulse oximeter to evaluate the client's oxygen saturation.Answer
  2. Report the sudden change in mental status and vital signs to the registered nurse (RN).Answer
  3. Inspect the surgical site and dressing for excessive drainage or bleeding.Answer
  4. D
    Document the acute confusion as a normal age-related response to hospitalization.
  5. E
    Monitor the vital signs at the next scheduled interval since the values are borderline.
  6. F
    Administer the prescribed PRN opioid analgesic to treat the underlying cause of agitation.

Answer

The correct actions are to apply a pulse oximeter, report the findings to the RN, and inspect the surgical site for bleeding.
The client is demonstrating early signs of acute physiological compromise, which could indicate hypoxia, fat embolism, or hypovolemic shock. Applying a pulse oximeter addresses the immediate need to evaluate respiratory status (ABCs). Inspecting the surgical site is essential to identify potential hemorrhage as a cause for the vital sign changes. Because this represents an acute, unstable change in condition, the PN must immediately report these findings to the RN to facilitate prompt medical intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has new-onset agitation, disorientation, tachypnea (26 breaths/min), tachycardia (109 beats/min), and borderline blood pressure (102/64 mm Hg).
Identifying abnormal data and subtle physiological cues is the first step in clinical judgment.
2
Determine the potential underlying complication.
These findings are early indicators of acute decompensation, such as hypovolemia, hemorrhage, or hypoxia (potentially from a fat embolism), rather than expected postoperative symptoms.
Connecting physiological changes to severe complications guides safe nursing interventions.
3
Prioritize nursing actions based on ABCs and scope of practice.
The PN must evaluate oxygenation (Breathing/Circulation), assess for bleeding (Circulation), and escalate care to the RN.
Airway, breathing, and circulation take priority in unstable clients, and acute changes must be reported immediately.

Key Concept

Early Recognition of Acute Decompensation and Hypovolemic Shock
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Topics

Physiological Adaptation

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