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Difficulty: HardPhysiological Adaptation

The practical nurse is caring for an older adult client who sustained a fractured right femur earlier in the day and is awaiting surgical repair. The client, who was previously alert, abruptly becomes highly agitated and exhibits confusion regarding their location. Current vital signs reveal a heart rate of 115 beats per minute, a respiratory rate of 24 breaths per minute, and a blood pressure of 96/58 mm Hg. Which action is the priority for the practical nurse to implement?

  1. Obtain an immediate oxygen saturation reading and prepare to administer supplemental oxygen.Answer
  2. B
    Reorient the client to the facility environment and ensure the bed alarm is activated.
  3. C
    Document the findings, as mild vital sign changes and confusion are anticipated in older adults following trauma.
  4. D
    Administer the scheduled as-needed dose of pain medication to alleviate the client's severe discomfort.

Answer

The correct action is to prioritize respiratory assessment and oxygenation by obtaining an oxygen saturation reading and preparing to administer supplemental oxygen.
The correct answer addresses the immediate threat to life by prioritizing respiratory assessment and oxygenation. A long bone fracture places the client at high risk for fat embolism syndrome and hypovolemic shock. The sudden onset of confusion, agitation, tachypnea, tachycardia, and borderline hypotension are early, critical clinical indicators of hypoxia and poor tissue perfusion. According to the ABC (airway, breathing, circulation) prioritization framework, evaluating and supporting oxygenation takes absolute precedence over safety interventions, routine monitoring, or pain management.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client has a long bone fracture and exhibits sudden confusion, severe agitation, tachypnea, tachycardia, and a low-normal blood pressure.
Identifying acute deviations from a stable baseline is essential for recognizing physiological deterioration.
2
Correlate the assessment findings with potential clinical complications.
The combination of long bone trauma and sudden respiratory and neurological changes strongly suggests a fat embolism or hypovolemic shock, both of which lead to severe hypoxia.
Connecting specific signs and symptoms to the client's risk factors guides accurate clinical judgment and intervention.
3
Apply prioritization frameworks to determine the initial nursing action.
Using the ABC (Airway, Breathing, Circulation) framework, the highest priority is to assess oxygenation status and provide respiratory support.
Life-threatening respiratory or circulatory issues must be stabilized before addressing safety, documentation, or pain management.

Key Concept

Prioritizing airway and breathing interventions in clients demonstrating acute signs of hypoxia and shock following long bone trauma.
Estimated Time:1m 15s
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Topics

Physiological Adaptation

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