A 28-year-old client is admitted to the intensive care unit following a high-speed motor v… — NCLEX-RN

A $28$ -year-old client is admitted to the intensive care unit following a high-speed motor vehicle collision. The client sustained a severe pelvic fracture and a right-sided pulmonary contusion. The client is intubated, mechanically ventilated, and sedated. The nurse evaluates the following clinical data:

Assessment Parameter	Client Data
Vital Signs	BP $78/42 \text{ mm Hg}$ , HR $138 \text{ beats/min}$ , RR $24 \text{ breaths/min}$
Oxygenation	$\text{SpO}_2$ $89\%$ on $\text{FiO}_2$ $0.60$
Hemodynamics	CVP $1 \text{ mm Hg}$ (normal $2$ - $8 \text{ mm Hg}$ )
Urine Output	$10 \text{ mL}$ over the past hour
Arterial Blood Gas	pH $7.21$ , $\text{PaCO}_2$ $54 \text{ mm Hg}$ , $\text{PaO}_2$ $58 \text{ mm Hg}$ , $\text{HCO}_3^-$ $15 \text{ mEq/L}$

Which of the following interventions should the nurse implement to mitigate the risk of severe physiological deterioration? (Select all that apply.)

Initiate a rapid intravenous infusion of warmed isotonic crystalloid fluids.Answer
Prepare for the emergent administration of uncrossmatched type O-negative packed red blood cells.Answer
C
Elevate the head of the bed to 90 degrees (high-Fowler's position) to maximize lung expansion.
D
Request a prescription for intravenous sodium bicarbonate to correct the elevated $\text{PaCO}_2$ level.
Defer non-essential nursing care such as a complete bed bath to cluster activities.Answer
F
Prioritize the administration of scheduled prophylactic subcutaneous enoxaparin.

Answer

The correct interventions are initiating a rapid infusion of warmed isotonic crystalloids, preparing for the administration of uncrossmatched type O-negative packed red blood cells, and deferring non-essential nursing care to cluster activities.

The client is experiencing profound hypovolemic (hemorrhagic) shock due to a severe pelvic fracture, evidenced by severe hypotension, tachycardia, a low CVP, and oliguria. Immediate fluid resuscitation with rapid, warmed isotonic crystalloids and uncrossmatched O-negative blood is essential to restore intravascular volume and tissue perfusion. Additionally, the client is in a state of severe mixed acidosis and hypoxemia; deferring non-essential physical care minimizes oxygen consumption and metabolic demand, protecting the precarious supply-demand balance.

Step-by-Step Solution

Analyze the client's vital signs, hemodynamics, and urine output.

The client exhibits profound hypotension (

78/42 \text{ mm Hg}

), marked tachycardia (

138 \text{ beats/min}

), a critically low CVP (

1 \text{ mm Hg}

), and severe oliguria (

10 \text{ mL/hr}

These findings collectively indicate class IV hypovolemic (hemorrhagic) shock secondary to the severe pelvic fracture, requiring immediate intravascular volume replacement with crystalloids and blood products.

Interpret the arterial blood gas (ABG) results in the context of the client's injuries.

The ABG reveals a severe mixed acidosis: respiratory acidosis from the pulmonary contusion (

\text{PaCO}_2

54 \text{ mm Hg}

) and metabolic (lactic) acidosis from systemic tissue hypoperfusion (

\text{HCO}_3^-

15 \text{ mEq/L}

Mixed acidosis confirms life-threatening physiological decompensation. Treatment must focus on restoring perfusion to clear lactic acid, rather than administering bicarbonate which would worsen the respiratory component.

Evaluate the impact of nursing interventions on oxygen supply and demand.

Routine activities (like bed baths) and extreme positioning (like high-Fowler's) increase oxygen consumption and decrease venous return.

In states of severe shock and hypoxemia, nursing care must be clustered and deferred to minimize myocardial oxygen demand and preserve cardiac output, necessitating the client remain supine.

Key Concept

Hemodynamic stabilization and reduction of physiological risk in mixed shock states

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