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Difficulty: HardPhysiological Adaptation

Four hours following an extensive bowel resection, a client reports severe thirst and exhibits new-onset restlessness. The nurse reviews the client's current clinical data:

ParameterCurrent ValuePreoperative Baseline
Blood Pressure104/76104/76 mm Hg134/82134/82 mm Hg
Heart Rate118118 beats/min7676 beats/min
Respiratory Rate2828 breaths/min1414 breaths/min
Oxygen Saturation96%96\% on room air98%98\% on room air

Recent arterial blood gas (ABG) results show a pH of 7.487.48, PaCO 2_2 of 3030 mm Hg, and HCO 3−_3^- of 2323 mEq/L.

Which of the following is the priority nursing action?

  1. Examine the surgical dressing and palpate the abdomen for rigidity or distension.Answer
  2. B
    Instruct the client to perform slow, paced breathing to correct the respiratory alkalosis.
  3. C
    Administer a prescribed intravenous anxiolytic to relieve the client's restlessness.
  4. D
    Initiate supplemental oxygen therapy at 2 L/min via nasal cannula to treat the tachypnea.

Answer

The priority action is to examine the surgical dressing and palpate the abdomen for rigidity or distension.
The client's presentation of restlessness, severe thirst, tachycardia, and a narrowing pulse pressure are hallmark signs of the compensatory stage of hypovolemic shock, likely due to internal hemorrhage following major abdominal surgery. The respiratory alkalosis is a compensatory response to sympathetic stimulation and poor tissue perfusion. The highest priority is to assess the source of the suspected bleeding by examining the surgical dressing and abdomen.

Step-by-Step Solution

1
Analyze the vital signs and clinical presentation.
The client exhibits tachycardia (118118 bpm), tachypnea (2828 breaths/min), a narrowing pulse pressure (from 5252 mm Hg to 2828 mm Hg), restlessness, and severe thirst.
Recognizing deviations from baseline is essential to identify early physiological deterioration.
2
Interpret the arterial blood gas (ABG) results.
The elevated pH (7.487.48) and low PaCO 2_2 (3030 mm Hg) with a normal HCO 3−_3^- (2323 mEq/L) indicate uncompensated respiratory alkalosis.
Understanding the acid-base balance helps determine if the respiratory changes are primary or a compensatory mechanism.
3
Synthesize the data to identify the primary problem.
The overall clinical picture strongly indicates the compensatory stage of hypovolemic (hemorrhagic) shock. The respiratory alkalosis is a secondary compensatory mechanism driven by sympathetic nervous system activation and poor tissue perfusion.
Prioritization requires identifying the root cause of the instability (Circulation) rather than treating isolated symptoms.
4
Determine the priority nursing intervention.
The nurse must immediately assess the surgical site and abdomen for evidence of internal or external hemorrhage before initiating further interventions.
Targeted assessment of the suspected source of circulatory loss dictates the subsequent life-saving resuscitation efforts.

Key Concept

Early recognition of hypovolemic shock and prioritization of circulatory assessment over compensatory symptoms.

Alternative Method

Use the pulse pressure calculation to detect early shock. The baseline pulse pressure was 5252 mm Hg (134−82134-82) and has narrowed significantly to 2828 mm Hg (104−76104-76). A narrowing pulse pressure is one of the earliest signs of volume depletion, occurring before a profound drop in systolic blood pressure.
Estimated Time:1m 30s
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Topics

Physiological Adaptation

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