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Difficulty: MediumPhysiological Adaptation

A practical nurse (PN) is assigned to care for an 84-year-old client who has experienced severe vomiting and diarrhea for the last 72 hours. The client's baseline blood pressure is typically 138/78 mm Hg. During the current observation, the PN notes the client is increasingly restless and disoriented. The vital signs are: blood pressure 104/62 mm Hg, heart rate 108 beats per minute, and respiratory rate 20 breaths per minute. Which of the following actions should the PN take? Select all that apply.

  1. Notify the registered nurse (RN) immediately about the changes in mental status and vital signs.Answer
  2. Ensure the patency of the client's peripheral intravenous (IV) catheter.Answer
  3. Administer supplemental oxygen as prescribed.Answer
  4. D
    Administer a prescribed as-needed (PRN) oral analgesic for abdominal cramping.
  5. E
    Document the findings and maintain the routine schedule of assessing vital signs every 4 hours.
  6. F
    Reorient the client to the surroundings and document the confusion as an expected age-related change.

Answer

The correct actions are to notify the registered nurse (RN) immediately about the changes, ensure the patency of the peripheral IV catheter, and administer supplemental oxygen as prescribed.
The correct actions prioritize recognizing and responding to the early signs of hypovolemic shock resulting from severe dehydration. Notifying the RN ensures appropriate escalation and medical intervention, ensuring IV patency prepares the client for necessary rapid fluid resuscitation, and administering oxygen addresses potential tissue hypoxia that is causing the client's new-onset restlessness.

Step-by-Step Solution

1
Analyze the client's history and presenting clinical data.
The client has a history of severe fluid loss (vomiting and diarrhea). Current findings reveal new-onset confusion, tachycardia (108 bpm), and a relative drop in blood pressure from 138/78 to 104/62 mm Hg.
Comparing current data against the client's baseline is essential to accurately identify physiological deterioration.
2
Correlate the assessment findings to a potential physiological complication.
The combination of significant fluid loss, borderline abnormal vital signs, and acute mental status changes indicates the early compensatory stages of hypovolemic shock.
Connecting clinical manifestations to their underlying pathophysiological cause guides nursing prioritization and intervention.
3
Select the most appropriate interventions within the practical nurse (PN) scope of practice.
The PN must escalate the findings to the RN, secure IV access for anticipated fluid resuscitation, and administer oxygen to support tissue perfusion.
In emergent situations, the PN plays a critical role in data collection, basic physiological support of airway, breathing, and circulation (ABCs), and rapid communication.

Key Concept

Early Recognition and Prioritization of Hypovolemic Shock
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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