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Difficulty: HardPhysiological Adaptation

Following shift report on a medical-surgical unit, a practical nurse (PN) reviews the data for four assigned clients. Which client's clinical presentation indicates a potential life-threatening complication and requires immediate escalation to the registered nurse (RN)?

  1. A
    A client with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 90%90\% on room air.
  2. B
    A client 11 day postoperative following an inguinal hernia repair who reports incisional pain rated 88 on a 00-to-1010 scale.
  3. A client with acute pancreatitis whose heart rate is 112112 beats/min and blood pressure is 98/6498/64 mm Hg.Answer
  4. D
    A client with chronic kidney disease (CKD) scheduled for hemodialysis who has a serum potassium level of 5.25.2 mEq/L.

Answer

The client with acute pancreatitis who has a heart rate of 112 beats/min and blood pressure of 98/64 mm Hg requires immediate escalation.
The client with acute pancreatitis is exhibiting tachycardia and hypotension. These are early, subtle signs of hypovolemic shock caused by massive fluid shifts (third-spacing) into the retroperitoneal cavity. This represents a life-threatening failure of physiological adaptation that requires immediate intravenous fluid resuscitation by the registered nurse.

Step-by-Step Solution

1
Analyze the client with COPD.
The oxygen saturation is 90% on room air.
Identify that a pulse oximetry reading of 88-92% is an expected, stable baseline for a client with chronic respiratory disease.
2
Analyze the client who is 1 day postoperative.
The client has severe pain (8/10).
Recognize that acute postoperative pain is expected and does not represent a life-threatening airway, breathing, or circulation (ABC) emergency.
3
Analyze the client with CKD.
The serum potassium level is 5.2 mEq/L.
Identify that a slightly elevated potassium level is a baseline expectation for a renal failure client awaiting their scheduled dialysis session.
4
Analyze the client with acute pancreatitis.
The client exhibits a heart rate of 112 beats/min and a blood pressure of 98/64 mm Hg.
Determine that these borderline vital signs represent early hypovolemic shock caused by severe fluid shifting (third-spacing) into the retroperitoneum, making this the highest priority.

Key Concept

Prioritization requires distinguishing between expected chronic abnormalities and subtle, acute physiological deterioration such as early hypovolemic shock.
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Topics

Physiological Adaptation

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