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Difficulty: MediumReduction of Risk Potential

A nurse is caring for an older adult client who underwent a right total hip arthroplasty 12 hours ago. During the assessment, the nurse notes the client is increasingly restless and confused. Vital parameters are: heart rate 118 beats per minute, blood pressure 92/60 mm Hg, and respiratory rate 28 breaths per minute. A point-of-care arterial blood sample reveals a pH of 7.28, PaCO2 of 56 mm Hg, and HCO3- of 24 mEq/L. Which initial action should the nurse take to minimize the risk of further clinical deterioration?

  1. Apply supplemental oxygen and notify the rapid response team.Answer
  2. B
    Elevate the head of the bed to a high-Fowler's position to facilitate chest expansion.
  3. C
    Administer a prescribed intravenous opioid analgesic to manage suspected acute pain.
  4. D
    Instruct the client to breathe slowly into a paper bag to correct the respiratory alkalosis.

Answer

Apply supplemental oxygen and notify the rapid response team.
The client is exhibiting early signs of shock and respiratory failure (tachycardia, hypotension, restlessness, confusion), which are critical complications following major orthopedic surgery like a total hip arthroplasty. The arterial blood gas confirms uncompensated respiratory acidosis (low pH, high PaCO2). Applying supplemental oxygen addresses the immediate physiological deficit, while activating the rapid response team brings critical care resources to manage the impending systemic collapse.

Step-by-Step Solution

1
Analyze the client's vital signs and clinical presentation.
The client is tachycardic, hypotensive, tachypneic, restless, and confused.
These are early clinical indicators of shock, hypoxia, or a complication such as a pulmonary embolism or hemorrhage, which require immediate life-saving intervention.
2
Interpret the point-of-care arterial blood gas values.
The pH is 7.28 (acidotic), PaCO2 is 56 mm Hg (elevated), and HCO3- is 24 mEq/L (normal).
This confirms uncompensated respiratory acidosis, meaning the client is retaining carbon dioxide and failing to ventilate adequately.
3
Select the intervention that best mitigates the acute risk without causing procedural harm.
Providing supplemental oxygen and activating the rapid response team is the safest and most effective initial action.
It supports the failing respiratory system while mobilizing the necessary advanced care providers to treat the underlying cause of shock.

Key Concept

Early recognition of shock and uncompensated respiratory acidosis in post-operative orthopedic clients.
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Topics

Reduction of Risk Potential

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