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Zorluk: KolayPhysiological Adaptation

An 82-year-old client who is recovering from a surgical repair of a fractured femur suddenly becomes agitated, confused, and has a respiratory rate of 28 breaths/minute. Which of the following actions should the practical nurse (PN) take? (Select all that apply.)

  1. Apply a pulse oximeter to measure the client's oxygen saturation level.Cevap
  2. Elevate the head of the client's bed to maximize chest expansion.Cevap
  3. Promptly notify the registered nurse (RN) about the acute changes in the client's condition.Cevap
  4. D
    Reassure the client's family that sudden confusion is a normal, expected part of the aging process.
  5. E
    Administer the prescribed as-needed (PRN) oral opioid analgesic to help reduce the client's agitation.
  6. F
    Delay reporting the findings until the client exhibits a significant drop in blood pressure.

Cevap

The correct actions include elevating the head of the bed, applying a pulse oximeter, and immediately notifying the registered nurse (RN).
The client's sudden onset of agitation, confusion, and tachypnea are early, critical signs of hypoxia or a potential fat embolism syndrome, a known complication of long bone fractures. The appropriate nursing response is to prioritize Airway and Breathing by elevating the head of the bed to facilitate lung expansion, applying a pulse oximeter to gather objective oxygenation data, and immediately notifying the RN to escalate care. These actions directly address the potential life-threatening physiological adaptation failure.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client has sudden confusion, agitation, and a respiratory rate of 28 breaths/minute following a femur fracture repair.
Identifying the onset and nature of symptoms is necessary to determine the level of urgency.
2
Apply the Airway, Breathing, and Circulation (ABC) prioritization framework.
Tachypnea and sudden confusion indicate a high probability of compromised breathing and oxygenation (e.g., hypoxia or fat embolism).
The ABC framework dictates that respiratory compromise must be addressed before pain management or routine care.
3
Select the immediate nursing interventions that support the ABCs and client safety.
Elevating the head of the bed improves breathing mechanics, applying a pulse oximeter provides objective oxygenation data, and notifying the RN ensures rapid escalation of care.
These actions are within the PN scope of practice and directly address the life-threatening potential of the client's symptoms.

Anahtar Kavram

Prioritization of care using the Airway, Breathing, and Circulation (ABC) framework during acute physiological decompensation.
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Physiological Adaptation

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