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Difficulty: HardPhysiological Adaptation

Following a fall from a roof, a client with a confirmed unstable pelvic fracture experiences a sudden change in condition during the afternoon shift. The client, previously calm, becomes exceedingly restless and reports an intense sensation of thirst. The bedside monitor displays a heart rate of 126 beats/min, a blood pressure reading of 90/54 mm Hg, and a respiratory rate of 26 breaths/min. The indwelling urinary catheter has drained 15 mL of dark urine in the last 60 minutes. Which of the following immediate interventions are required? Select all that apply.

  1. Apply a supplemental oxygen delivery device.Answer
  2. Prepare for rapid replacement of intravascular volume using isotonic crystalloids.Answer
  3. C
    Give the as-needed dose of opioid analgesic to alleviate the sudden restlessness.
  4. D
    Elevate the head of the bed to a 90-degree angle to help calm the client.

Answer

The correct interventions are applying a supplemental oxygen delivery device and preparing for rapid replacement of intravascular volume using isotonic crystalloids.
The client is exhibiting classic signs of early compensatory hemorrhagic shock secondary to a pelvic fracture. Symptoms include tachycardia, hypotension, tachypnea, oliguria, intense thirst, and restlessness (a key early sign of cerebral hypoxia). The priority nursing actions are to maximize tissue oxygenation by applying supplemental oxygen and to restore circulating blood volume by preparing for rapid isotonic intravenous fluid administration.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client exhibits tachycardia, hypotension, tachypnea, severe oliguria, thirst, and new-onset restlessness after sustaining a high-risk injury (pelvic fracture).
Identifying abnormal assessment findings is the first step in recognizing a life-threatening complication such as hemorrhagic shock.
2
Determine the priority pathophysiological needs based on the ABCs (Airway, Breathing, Circulation).
The client requires immediate interventions to support oxygenation and restore depleted intravascular volume.
Hemorrhagic shock leads to inadequate cellular perfusion. Intervening promptly prevents progression to irreversible shock and multiorgan failure.
3
Evaluate the proposed interventions against the client's physiological state.
Oxygen therapy and fluid resuscitation address the core pathophysiology. Opioids and high-Fowler's positioning are contraindicated as they exacerbate hypotension and hypoperfusion.
Nursing actions must prioritize physiological stabilization and avoid interventions that mask symptoms or mechanically decrease cardiac output.

Key Concept

Early Recognition and Management of Hypovolemic Shock
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Topics

Physiological Adaptation

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