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Zorluk: OrtaPhysiological Adaptation

A practical nurse (PN) is caring for an older adult client who was admitted with a severe urinary tract infection. The client suddenly becomes highly restless, exhibits a respiratory rate of 28 breaths/min, and has a blood pressure that decreased from 132/80 mm Hg to 96/58 mm Hg. Which actions should the PN take in this situation? Select all that apply.

  1. Notify the registered nurse (RN) immediately regarding the client's change in status.Cevap
  2. Verify the patency of the client's existing intravenous (IV) access.Cevap
  3. Prepare to administer supplemental oxygen as prescribed.Cevap
  4. D
    Administer the scheduled oral analgesic for reported suprapubic discomfort.
  5. E
    Document the findings and wait one hour to reassess the blood pressure.
  6. F
    Reassure the family that the sudden restlessness is a normal age-related change.

Cevap

The correct actions are to notify the RN immediately, verify IV access patency, and prepare to administer supplemental oxygen.
The client is demonstrating early signs of septic shock, including restlessness (decreased cerebral perfusion), tachypnea, and a dropping blood pressure. The PN must immediately prioritize Airway, Breathing, and Circulation (ABC) while rapidly escalating care. Notifying the RN facilitates prompt medical intervention, checking IV patency prepares the client for emergent fluid or medication administration, and providing oxygen supports systemic tissue perfusion.

Adım Adım Çözüm

1
Analyze the client's changing clinical data.
The client has a severe infection and now presents with restlessness, tachypnea (28 breaths/min), and a dropping blood pressure (96/58 mm Hg).
Recognizing trends in vital signs and mental status is essential for identifying early septic shock.
2
Prioritize interventions based on the ABC (Airway, Breathing, Circulation) framework.
The PN must address the client's systemic circulatory and respiratory compromise before addressing localized symptoms like pain.
Acute physiological deterioration requires immediate stabilizing care and escalation to prevent mortality.
3
Select the appropriate actions within the PN scope of practice.
The PN should prepare oxygen (Breathing), check IV patency for fluids (Circulation), and notify the RN for advanced orders (Escalation).
These actions are safe, immediate, and fall directly within the expected response protocols for a PN.

Anahtar Kavram

Early recognition and prioritization of care for septic shock.
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Konular

Physiological Adaptation

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