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Difficulty: MediumPhysiological Adaptation

A practical nurse is providing care for a client who is on strict bed rest for a deep vein thrombosis. The client abruptly becomes restless and confused, exhibiting a respiratory rate of 24 breaths per minute and a heart rate of 98 beats per minute (baseline 72 beats per minute). The client also reports a vague sense of impending doom. Which action should the practical nurse take first?

  1. A
    Administer the prescribed PRN antianxiety medication for the sudden agitation.
  2. B
    Examine the affected extremity for any new changes in swelling or redness.
  3. Elevate the head of the client's bed and notify the registered nurse.Answer
  4. D
    Document the vital sign changes and continue to monitor the client closely.

Answer

Elevate the head of the client's bed and notify the registered nurse.
The client is exhibiting classic signs of a pulmonary embolism, a life-threatening complication of a deep vein thrombosis. The immediate priority is to support the client's breathing by elevating the head of the bed (high-Fowler's position) to maximize lung expansion. Because this is a medical emergency requiring advanced interventions, the practical nurse must simultaneously notify the registered nurse to activate a rapid medical response.

Step-by-Step Solution

1
Analyze the clinical presentation and client history.
The client has a known deep vein thrombosis and has suddenly developed restlessness, confusion, tachypnea (24 breaths/min), tachycardia (98 beats/min), and a sense of impending doom.
Identifying these classic signs is crucial for recognizing a potential pulmonary embolism, a severe complication of a deep vein thrombosis.
2
Determine the priority framework.
Apply the Airway, Breathing, and Circulation (ABC) prioritization framework.
A pulmonary embolism primarily compromises breathing and circulation, representing a life-threatening medical emergency.
3
Select the most appropriate initial nursing intervention.
Elevating the head of the bed supports the client's respiratory effort, and notifying the registered nurse initiates the rapid medical response required.
The practical nurse must take immediate actions within their scope of practice to protect the airway and escalate care for acute instability.

Key Concept

Recognition of Pulmonary Embolism and ABC Prioritization
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Topics

Physiological Adaptation

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