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Difficulty: Very hardPhysiological Adaptation

A 75-year-old client who sustained a closed right femur fracture 24 hours ago suddenly becomes intensely restless and confused. The practical nurse (PN) notes an apical heart rate of 108 beats per minute and a respiratory rate of 24 breaths per minute. Which immediate actions should the PN take? Select all that apply.

  1. Obtain an immediate, comprehensive set of vital signs including continuous pulse oximetry.Answer
  2. Inspect the client's anterior chest, neck, and axillae for the presence of a petechial rash.Answer
  3. Promptly notify the registered nurse (RN) regarding the acute change in the client's status.Answer
  4. D
    Reassure the family that this sudden confusion is a normal, expected reaction to the hospital environment in older adults.
  5. E
    Administer the prescribed as-needed (PRN) opioid analgesic to decrease the client's intense restlessness.
  6. F
    Continue routine monitoring, as mild tachycardia and restlessness are expected findings the day after major orthopedic trauma.

Answer

The correct actions are to obtain a comprehensive set of vital signs with pulse oximetry, inspect the chest and neck for a petechial rash, and promptly notify the RN.
The correct actions focus on immediate ABC (Airway, Breathing, Circulation) assessment, targeted data collection for a specific life-threatening complication of long bone fractures (Fat Embolism Syndrome), and rapid escalation. Restlessness and tachypnea 24 hours after a long bone fracture are classic early signs of hypoxia and fat emboli.

Step-by-Step Solution

1
Analyze the clinical cues provided in the scenario.
The client has restlessness, confusion, tachycardia (108 bpm), and tachypnea (24 breaths/min) exactly 24 hours after a long bone fracture.
These specific findings strongly suggest the onset of Fat Embolism Syndrome (FES) or hypoxia, which requires immediate physiological intervention.
2
Prioritize initial bedside assessment based on the Airway, Breathing, Circulation (ABC) framework.
The PN must immediately assess oxygenation status via continuous pulse oximetry and complete a full set of vital signs.
Restlessness is the earliest sign of hypoxia; obtaining exact perfusion data is critical before any other intervention.
3
Perform targeted, condition-specific data collection.
The PN inspects the client's chest, neck, and axillae for petechiae.
Identifying a petechial rash is a classic hallmark sign that distinguishes Fat Embolism Syndrome from other causes of postoperative hypoxia or delirium.
4
Execute appropriate escalation of care within the practical nursing scope of practice.
The PN immediately reports the acute change in neurological and respiratory status to the supervising RN.
Suspected systemic complications like FES require immediate collaborative management, advanced assessment, and potential transfer to an intensive care setting.

Key Concept

Recognizing and rapidly responding to Fat Embolism Syndrome (FES) and acute hypoxia prioritizing ABCs.
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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