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Difficulty: HardPhysiological Adaptation

A nurse is caring for a client who is 4 hours postoperative following an open abdominal aortic aneurysm (AAA) repair. The client exhibits new-onset restlessness and anxiety. Current vital signs include a heart rate of 118 bpm, blood pressure of 102/84 mm Hg, and a respiratory rate of 24 breaths/min. Urine output was 15 mL over the past hour. Arterial blood gas (ABG) results show a pH of 7.28, PaCO2 of 34 mm Hg, and HCO3- of 15 mEq/L. Based on these findings, which of the following actions should the nurse perform? Select all that apply.

  1. Initiate a rapid infusion of prescribed isotonic intravenous fluids.Answer
  2. B
    Administer the prescribed PRN intravenous furosemide to increase urine output.
  3. Anticipate the need to obtain a type and crossmatch for packed red blood cells.Answer
  4. D
    Elevate the head of the bed to a high-Fowler's position to improve ventilation.
  5. Apply supplemental oxygen via a non-rebreather mask.Answer
  6. F
    Prepare to administer intravenous sodium bicarbonate to correct the respiratory acidosis.

Answer

The nurse should initiate a rapid infusion of isotonic intravenous fluids, anticipate the need for a type and crossmatch for blood products, and apply supplemental oxygen.
The client is exhibiting classic signs of compensatory hypovolemic (likely hemorrhagic) shock following major vascular surgery. These signs include a narrowing pulse pressure (18 mm Hg), tachycardia, restlessness, and oliguria. The ABG reveals metabolic acidosis, which is caused by lactic acid accumulation from poor tissue perfusion. The correct actions directly address these life-threatening physiological changes: initiating isotonic fluids and anticipating blood transfusions will restore intravascular volume and oxygen-carrying capacity, while applying supplemental oxygen maximizes oxygen delivery to ischemic tissues.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client has a narrow pulse pressure (102 - 84 = 18 mm Hg), tachycardia, restlessness, and oliguria, which are hallmark signs of compensatory hypovolemic or hemorrhagic shock.
Recognizing early shock is critical, especially in high-risk postoperative vascular patients.
2
Interpret the arterial blood gas (ABG) results.
The pH is low (7.28), PaCO2 is normal to low (34 mm Hg), and HCO3- is low (15 mEq/L), indicating an uncompensated metabolic acidosis.
Metabolic acidosis in the context of shock is typically lactic acidosis resulting from inadequate tissue perfusion and anaerobic metabolism.
3
Select interventions that address the underlying pathophysiology.
Priority interventions must focus on restoring circulating volume (fluids, blood) and maximizing oxygenation to reverse tissue hypoperfusion.
Treating the root cause (hypovolemia/hemorrhage) is required to correct the shock state and the resulting metabolic derangements.

Key Concept

Recognition and management of compensatory hypovolemic shock and metabolic acidosis
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Topics

Physiological Adaptation

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