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Zorluk: OrtaPhysiological Adaptation

A practical nurse (PN) is assigned to care for a 78-year-old client with a history of chronic kidney disease who is receiving a continuous intravenous (IV) infusion of normal saline at 125 mL/hr. During hourly rounds, the client suddenly becomes restless, repeatedly asks where they are, and exhibits a respiratory rate of 26 breaths/min with a heart rate of 104 beats/min. Which action should the PN take FIRST?

  1. Elevate the head of the bed and measure the client's oxygen saturation.Cevap
  2. B
    Apply a bed alarm and gently reorient the client to their current surroundings.
  3. C
    Ask another nurse to stay with the client while checking the medication record for an ordered anxiolytic.
  4. D
    Document the client's vital signs and plan to reassess the respiratory status in one hour.

Cevap

The correct action is to elevate the head of the bed and measure the client's oxygen saturation.
Restlessness and acute confusion in an older adult, especially when accompanied by an increased respiratory rate and heart rate during continuous IV fluid therapy, are early signs of hypoxia secondary to fluid volume overload. Elevating the head of the bed rapidly promotes lung expansion, and measuring oxygen saturation provides immediate, critical data regarding the client's respiratory status before notifying the registered nurse (RN).

Adım Adım Çözüm

1
Analyze the client's presentation and medical history.
The client is elderly, has chronic kidney disease, is receiving continuous IV fluids, and presents with new-onset restlessness, confusion, tachypnea, and tachycardia.
Identifying risk factors (kidney disease, IV fluids) combined with acute symptom changes is necessary to determine the underlying physiological problem.
2
Correlate the assessment findings with potential complications.
The findings strongly suggest fluid volume overload leading to pulmonary congestion and subsequent hypoxia.
Restlessness and acute confusion in older adults are often the earliest signs of poor oxygenation, rather than a primary psychological issue.
3
Prioritize the nursing interventions using the ABC (Airway, Breathing, Circulation) framework.
Facilitating breathing by elevating the head of the bed and obtaining an oxygen saturation reading becomes the absolute priority.
Immediate physical positioning improves respiratory mechanics, and pulse oximetry provides actionable data to report to the registered nurse (RN).

Anahtar Kavram

Prioritization of care for fluid volume overload and hypoxia in susceptible clients.
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Konular

Physiological Adaptation

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