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Difficulty: MediumPhysiological Adaptation

An 81-year-old client is recuperating on the surgical unit 48 hours after a pelvic fracture repair. The client's visiting family member alerts the nursing staff, stating the client is suddenly acting agitated and asking when the train is arriving. The client's current vital signs show a heart rate of 106 beats/min, a respiratory rate of 22 breaths/min, a blood pressure of 104/64 mmHg, and an oxygen saturation of 91% on room air. Which action should the practical nurse (PN) take first?

  1. Elevate the head of the bed and initiate prescribed supplemental oxygen therapy.Answer
  2. B
    Administer the prescribed as-needed (PRN) analgesic to help calm the client's agitation.
  3. C
    Record the current data and plan to reassess the client's vital signs in four hours.
  4. D
    Reassure the family that intermittent confusion is a normal expectation for older adults after surgery.

Answer

The priority action is to elevate the head of the bed and initiate prescribed supplemental oxygen therapy.
The correct action directly addresses the client's immediate physiological threat. Sudden confusion and agitation in an older adult, especially with an oxygen saturation of 91%, tachycardia, and tachypnea, strongly indicate hypoxia. By elevating the head of the bed and applying oxygen, the practical nurse supports the client's airway and breathing, adhering to the ABC priority framework.

Step-by-Step Solution

1
Analyze the client's sudden change in mental status (agitation, confusion) alongside the vital signs.
The client has an oxygen saturation of 91%, a heart rate of 106 beats/min, and a respiratory rate of 22 breaths/min.
Identifying abnormal clinical data helps pinpoint the underlying physiological cause of the sudden confusion.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework to the findings.
The findings point to an issue with 'Breathing' and oxygenation (hypoxia), which takes precedence over pain management or routine monitoring.
According to the ABC framework, life-threatening respiratory issues must be addressed before secondary symptoms like agitation.
3
Select the nursing intervention that directly treats the identified problem.
Elevating the head of the bed promotes lung expansion, and administering supplemental oxygen directly corrects the hypoxemia.
Immediate physiological adaptation interventions are necessary to stabilize the client and prevent further deterioration.

Key Concept

Prioritizing ABCs and Recognizing Acute Delirium from Hypoxia
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Topics

Physiological Adaptation

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