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Difficulty: MediumPhysiological Adaptation

Following a high-speed collision, an adult client is brought into the trauma bay with a suspected splenic laceration. Initial assessment reveals generalized restlessness, pale mucous membranes, a blood pressure of 96/76 mm Hg, and an apical pulse of 118 beats/min. A stat arterial blood gas panel indicates a pH of 7.29, PaCO2 of 35 mm Hg, and HCO3 of 16 mEq/L. Which intervention should the nurse implement immediately?

  1. Initiate rapid intravenous infusion of an isotonic crystalloid solutionAnswer
  2. B
    Administer prescribed intravenous sodium bicarbonate to correct the acidosis
  3. C
    Administer a prescribed intravenous opioid to manage restlessness and suspected pain
  4. D
    Prepare the client for an immediate abdominal computed tomography (CT) scan

Answer

Initiate rapid intravenous infusion of an isotonic crystalloid solution
The client's narrow pulse pressure, tachycardia, restlessness, and metabolic acidosis all point to hemorrhagic shock and poor tissue perfusion. The most critical immediate action is to restore circulating volume using isotonic fluids to improve blood pressure, cardiac output, and cellular oxygen delivery.

Step-by-Step Solution

1
Analyze the vital signs and physical assessment findings.
The client has a narrow pulse pressure of 20 mm Hg (96 - 76 = 20), tachycardia (118 beats/min), restlessness, and pale mucous membranes.
These findings are classic early indicators of compensatory hypovolemic (hemorrhagic) shock due to acute blood loss.
2
Interpret the arterial blood gas (ABG) results.
A pH of 7.29 and HCO3 of 16 mEq/L indicate metabolic acidosis.
In the context of trauma and hypoperfusion, this represents lactic acidosis caused by anaerobic metabolism from inadequate cellular oxygen delivery.
3
Prioritize the immediate nursing interventions based on the ABCs (Airway, Breathing, Circulation).
The immediate priority is restoring circulating blood volume to support circulation and perfusion.
Administering isotonic crystalloids addresses the root cause of both the shock and the secondary metabolic acidosis.

Key Concept

Recognizing and managing hypovolemic shock and secondary lactic acidosis in trauma clients.
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Topics

Physiological Adaptation

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