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Difficulty: MediumPhysiological Adaptation

A client who underwent a total hip arthroplasty 24 hours ago is found pulling at their intravenous tubing. The client, who was fully oriented during the morning assessment, is now highly restless and disoriented to place. The current heart rate is 112 beats per minute and the respiratory rate is 26 breaths per minute. What is the priority action for the practical nurse in this situation?

  1. A
    Inform family members that temporary confusion is an expected, normal finding in older adults after major surgery.
  2. B
    Contact the provider to obtain a prescription for an anti-anxiety medication to control the agitated behavior.
  3. Obtain a pulse oximetry reading and immediately evaluate the client's respiratory status.Answer
  4. D
    Log the mild tachycardia in the medical record and proceed with the standard scheduled checks.

Answer

The priority action is to evaluate the client's respiratory status by obtaining a pulse oximetry reading and assessing the airway and breathing.
Sudden onset of restlessness, agitation, and confusion, particularly when accompanied by tachypnea and tachycardia, are classic early indicators of hypoxia. Because this client is 24 hours post-hip arthroplasty, they are at high risk for a pulmonary embolism or fat embolism. The nurse must prioritize the 'Airway and Breathing' components of the ABC framework by immediately evaluating the client's oxygenation status before considering other interventions.

Step-by-Step Solution

1
Analyze the clinical cues presented by the client.
The client exhibits sudden restlessness, disorientation, tachycardia, and tachypnea 24 hours post-surgery.
Identifying acute deviations from a client's baseline is the first step in clinical reasoning and recognizing complications.
2
Determine the most life-threatening potential cause for these new symptoms.
Sudden agitation and confusion, accompanied by increased heart and respiratory rates, are hallmark early signs of hypoxia (such as from a pulmonary embolism or fat embolism).
Prioritization requires addressing airway, breathing, and circulation (ABC) before considering secondary psychological or environmental concerns.
3
Select the intervention that directly addresses the highest priority need.
Assessing oxygenation status is the immediate priority to rule out or confirm a life-threatening respiratory compromise.
Nursing interventions must follow the ABC framework; assessing respiratory function takes precedence over administering sedatives or performing routine documentation.

Key Concept

Hypoxia Recognition and ABC Prioritization
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Topics

Physiological Adaptation

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