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Difficulty: MediumPhysiological Adaptation

A client who underwent a total knee arthroplasty 12 hours ago suddenly becomes restless, continuously picking at the bedsheets, and asking for a family member who is not present. The surgical dressing is dry and intact. Current vital signs are: heart rate 114 bpm, blood pressure 104/62 mm Hg, and respiratory rate 24 breaths/min. Which action should the practical nurse prioritize?

  1. Obtain a pulse oximetry reading to check oxygen saturation.Answer
  2. B
    Reorient the client to the time, place, and situation.
  3. C
    Administer the prescribed as-needed analgesic for postoperative pain.
  4. D
    Document the findings and recheck vital signs in one hour.

Answer

Obtain a pulse oximetry reading to check oxygen saturation.
Sudden restlessness, agitation, and confusion in a postoperative client are primary indicators of underlying physiological compromise, most commonly hypoxia or early hemorrhagic shock. The borderline elevated heart rate and respiratory rate further support a compensatory physiological response. The priority action within the practical nursing scope is to immediately collect focused data on the client's respiratory and oxygenation status to identify or rule out hypoxia before implementing other measures.

Step-by-Step Solution

1
Analyze the client's new-onset symptoms.
The client is exhibiting sudden restlessness, confusion, borderline tachycardia (114 bpm), and tachypnea (24 breaths/min).
Identifying acute deviations from the baseline status is the crucial first step in clinical judgment.
2
Correlate symptoms with potential postoperative physiological complications.
Sudden restlessness and altered mental status in a postoperative client are primary early indicators of hypoxia or impaired perfusion.
Physiological adaptation issues must be investigated before assuming psychological or cognitive causes for confusion.
3
Determine the priority nursing intervention within the PN scope of practice.
Gathering specific data regarding the client's respiratory status directly addresses the most life-threatening potential cause.
Airway and Breathing (ABCs) always take priority in emergent or acute status changes.

Key Concept

Early Recognition of Hypoxia and Shock
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Topics

Physiological Adaptation

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