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Difficulty: MediumPhysiological Adaptation

An older adult client is hospitalized with severe lower extremity cellulitis and is receiving intravenous antibiotic therapy. Over a 4-hour period, the client's urine output totals 55 mL. The client's resting heart rate has trended upward from 78 to 96 beats/min, and blood pressure has trended downward from 132/78 to 106/62 mm Hg. The client now appears unusually agitated and is unsure of their location. Which actions should the practical nurse take? Select all that apply.

  1. Report the changing clinical parameters to the supervising registered nurse immediately.Answer
  2. Evaluate the client's lung sounds, respiratory rate, and pulse oximetry readings.Answer
  3. Anticipate assisting the registered nurse with a rapid intravenous fluid bolus or stat laboratory draws.Answer
  4. D
    Attribute the altered mental status to expected age-related changes and minimize room stimulation.
  5. E
    Maintain the current frequency of data collection because the vital signs have not reached critical threshold levels.
  6. F
    Prioritize giving the client's scheduled oral analgesic to ensure comfort before conducting further assessments.

Answer

The correct actions are to report the changing clinical parameters to the supervising registered nurse immediately, evaluate the client's respiratory status, and anticipate assisting with rapid fluid resuscitation or laboratory draws.
The client is exhibiting early signs of decreased tissue perfusion and potential systemic inflammatory response syndrome (SIRS) or sepsis, evidenced by oliguria, tachycardia, a downward trend in blood pressure, and altered mental status. Immediate escalation to the RN, evaluating respiratory function (ABCs), and preparing for rapid therapeutic interventions (like fluids and cultures) are critical, life-saving actions within the practical nurse's scope of practice.

Step-by-Step Solution

1
Analyze the clinical cues presented in the scenario.
The client has oliguria (55 mL over 4 hours is roughly 14 mL/hr, which is well below the minimum 30 mL/hr), a rising heart rate, falling blood pressure, and new-onset agitation.
Recognizing abnormal assessment data is the first step in clinical judgment.
2
Synthesize the cues to identify the underlying physiological problem.
The combination of these subtle but progressive signs indicates early systemic hypoperfusion, likely related to sepsis from the severe cellulitis.
Understanding the pathophysiology of infection leading to shock helps determine the urgency of the situation.
3
Determine the appropriate practical nurse interventions.
The priority is to maintain ABCs (assessing respiratory status), immediately escalate the findings to the RN for rapid medical management, and prepare to assist with emergency interventions.
The PN scope of practice requires prompt reporting of unstable physiological changes and assisting the healthcare team in stabilizing the client.

Key Concept

Early recognition of shock and physiological deterioration
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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