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Difficulty: HardPhysiological Adaptation

During hourly rounds on a medical-surgical unit, the practical nurse observes that an 81-year-old client being treated for bacterial pneumonia has become highly agitated and is picking at the bedsheets. The client's resting heart rate has increased to 112 beats per minute, and blood pressure has decreased to 102/62 mmHg from a morning baseline of 136/82 mmHg. Which action should the practical nurse take first?

  1. A
    Institute strict fall precautions and activate a bed alarm
  2. B
    Request a prescription for a mild sedative to calm the client
  3. Obtain a peripheral oxygen saturation readingAnswer
  4. D
    Document the current vital signs and plan to reassess in one hour

Answer

Obtain a peripheral oxygen saturation reading
The correct answer prioritizes the assessment of oxygenation. In clients with respiratory conditions like pneumonia, sudden agitation or restlessness is often the earliest sign of hypoxia. The accompanying tachycardia and hypotension further suggest acute physiological decompensation. The practical nurse must immediately gather focused respiratory data to determine if the client is experiencing compromised breathing and circulation.

Step-by-Step Solution

1
Analyze the clinical cues presented by the client.
The client has a respiratory infection, new-onset agitation, tachycardia (112 bpm), and dropping blood pressure (102/62 mmHg).
Identifying the combination of neurological and cardiovascular changes helps recognize acute physiological decompensation.
2
Apply the ABC (Airway, Breathing, Circulation) priority framework.
The symptoms suggest impaired oxygenation (Breathing) or early shock (Circulation).
Sudden confusion or agitation in an older adult, especially with an underlying respiratory illness, is a classic sign of hypoxia and must be investigated immediately.
3
Determine the most appropriate immediate action within the practical nurse scope.
Obtaining an oxygen saturation reading rapidly assesses the client's respiratory status.
Measuring oxygen saturation directly evaluates the most likely life-threatening cause of the client's sudden status change.

Key Concept

Prioritization of Airway, Breathing, and Circulation in Acute Decompensation
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Topics

Physiological Adaptation

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