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Difficulty: MediumPhysiological Adaptation

During the night shift, a nurse is evaluating an 82-year-old client who had a partial gastrectomy 48 hours ago. The client, who was previously resting quietly, is now agitated, confused, and trying to pull off the surgical dressing. Clinical findings include a heart rate of 118 beats/min, a respiratory rate of 26 breaths/min, and a blood pressure of 100/62 mm Hg. The client is rubbing their abdomen and groaning. Which action should the nurse prioritize?

  1. Assess the client's oxygen saturation level and apply prescribed supplemental oxygen.Answer
  2. B
    Administer the prescribed breakthrough analgesic to alleviate the client's abdominal discomfort.
  3. C
    Reorient the client to the hospital environment and dim the room lights to encourage sleep.
  4. D
    Document the current findings and resume hourly monitoring, as the vital signs remain within acceptable post-surgical parameters.

Answer

The priority action is to assess the client's oxygen saturation level and apply prescribed supplemental oxygen.
The client is exhibiting early signs of hypoxia and potential shock, indicated by new-onset agitation, tachycardia, tachypnea, and borderline hypotension. In the physiological adaptation phase following surgery, acute changes in mental status combined with these vital signs prioritize the need for immediate respiratory support and oxygenation assessment based on the ABCs.

Step-by-Step Solution

1
Analyze the client's change in mental status and vital signs.
The client exhibits sudden onset agitation, tachycardia (118 beats/min), tachypnea (26 breaths/min), and borderline hypotension (100/62 mm Hg).
Recognizing acute changes is essential for identifying potential life-threatening complications such as shock or hypoxia in the post-operative period.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
The client's symptoms strongly suggest impaired oxygenation, which takes clinical precedence over pain management or environmental modifications.
The ABC framework guides nurses to address the most critical and immediate threats to life first.
3
Determine the initial nursing intervention.
Assessing oxygenation status and providing prescribed respiratory support directly addresses the most critical physiological need.
Restoring adequate oxygenation is the immediate priority before treating pain or attempting to reorient a confused client.

Key Concept

Recognizing early signs of physiological decompensation and applying ABC prioritization.
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Topics

Physiological Adaptation

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