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Zorluk: OrtaReduction of Risk Potential

An LPN/LVN is caring for a 76-year-old client who is two days postoperative following a total hip arthroplasty. The client, who was previously alert and oriented, suddenly becomes agitated, disoriented, and attempts to climb out of bed. Which of the following is the priority action for the LPN/LVN to take?

  1. A
    Reassure the client's family that sudden confusion is an expected reaction to unfamiliar hospital surroundings in older adults.
  2. B
    Administer the prescribed as-needed (PRN) oral analgesic, assuming the sudden agitation is caused by uncontrolled surgical pain.
  3. Obtain a complete set of vital signs, including oxygen saturation, and report the findings to the registered nurse.Cevap
  4. D
    Contact the healthcare provider to request a prescription for soft limb restraints to ensure the client's safety.

Cevap

Obtain a complete set of vital signs, including oxygen saturation, and report the findings to the registered nurse.
Sudden onset of confusion, agitation, or delirium in an older adult, especially postoperatively, is often an early sign of a physiological problem such as hypoxia, infection, or hemorrhage. Obtaining a full set of vital signs, including oxygen saturation, prioritizes the Airway, Breathing, and Circulation (ABC) framework. It provides essential objective data to identify or rule out life-threatening conditions, which must then be immediately reported to the registered nurse for further clinical judgment.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
An older adult client is exhibiting sudden onset agitation and confusion two days after major joint surgery.
Recognizing an acute change in baseline mental status is the critical first step in the clinical judgment process.
2
Apply prioritization frameworks (ABCs and the Nursing Process).
Assessment (gathering vital signs) must precede intervention (medication or restraints), and physiological needs (oxygenation/perfusion) take priority over assumed discomfort.
Sudden confusion is a classic early sign of hypoxia or shock in postoperative clients, which are life-threatening if missed.
3
Select the action that addresses the highest priority physiological need within the LPN/LVN scope.
Obtaining vital signs provides objective data to rule out hypoxia and other acute physiological changes, which can then be escalated.
This action directly aligns with reducing risk potential by identifying clinical deterioration early and safely.

Anahtar Kavram

Prioritizing Physiological Assessment in Acute Delirium
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Konular

Reduction of Risk Potential

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