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Difficulty: MediumPhysiological Adaptation

The nurse receives the shift report for four clients on a medical-surgical unit. Which client should the nurse assess first?

  1. A
    A client with chronic obstructive pulmonary disease (COPD) whose recent arterial blood gas shows a pH of 7.33, PaCO2 of 52 mm Hg, and HCO3 of 26 mEq/L.
  2. B
    A client who is 4 hours post-appendectomy, rating incisional pain as 8 on a 0-10 scale, and requesting pain medication.
  3. A client with a pelvic fracture whose blood pressure changed from 128/74 mm Hg to 118/84 mm Hg and resting heart rate increased from 84 to 108 bpm.Answer
  4. D
    A client with heart failure who has a recorded weight gain of 1.5 lb (0.7 kg) since admission yesterday and chronic 1+ pitting pedal edema.

Answer

The client with a pelvic fracture, narrowing pulse pressure, and tachycardia.
The correct answer identifies the client exhibiting early signs of shock. Pelvic fractures carry a high risk of massive internal hemorrhage. The client's vital signs show a narrowing pulse pressure (systolic blood pressure decreasing while diastolic increases) and tachycardia, indicating compensatory mechanisms are attempting to maintain cardiac output in the face of fluid volume loss. This client is the most unstable and requires immediate intervention to prevent progression to decompensated shock.

Step-by-Step Solution

1
Identify the clinical status and potential risks for each client based on the provided data.
Three clients have expected or stable chronic findings, while one client has acute vital sign changes.
Systematic evaluation ensures the most unstable client is identified.
2
Analyze the arterial blood gas values for the client with COPD.
The values (pH 7.33, PaCO2 52, HCO3 26) indicate compensated respiratory acidosis, typical for chronic COPD.
Understanding baseline versus acute changes prevents unnecessary prioritization of stable chronic conditions.
3
Analyze the vital sign changes in the client with a pelvic fracture.
The pulse pressure narrowed from 54 mm Hg to 34 mm Hg, accompanied by tachycardia.
These are classic early compensatory signs of hypovolemic shock, a major risk with pelvic fractures.
4
Apply the ABCs (Airway, Breathing, Circulation) prioritization framework.
The client in early shock has a critical Circulation impairment, taking precedence over pain management or chronic edema.
Life-threatening acute changes must be addressed before expected post-operative findings or chronic disease management.

Key Concept

Prioritization of care and recognition of early hypovolemic shock
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Topics

Physiological Adaptation

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