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Soru

Zorluk: ZorPhysiological Adaptation

A practical nurse (PN) is caring for a 74-year-old client who sustained a closed pelvic fracture 40 hours ago. The client, who was previously alert and cooperative, is now picking at the bedsheets and speaking to a deceased relative. Current vital signs are: heart rate 116 bpm, respiratory rate 26 breaths/min, blood pressure 104/62 mm Hg, and oxygen saturation 89% on room air. Which action should the PN take first?

  1. Apply supplemental oxygen and urgently notify the registered nurse.Cevap
  2. B
    Reorient the client to the current time and place while minimizing environmental noise.
  3. C
    Assess the client's pain level using an appropriate scale and administer prescribed analgesia.
  4. D
    Document the findings and plan to reassess the client's vital signs in one hour.

Cevap

The correct action is to apply supplemental oxygen and urgently notify the registered nurse.
The client is exhibiting classic signs of acute hypoxia and potentially fat embolism syndrome, a life-threatening complication associated with pelvic fractures. The sudden onset of confusion, combined with tachypnea (RR 26), tachycardia (HR 116), and an oxygen saturation of 89%, indicates severe respiratory and hemodynamic compromise. According to the ABCs (Airway, Breathing, Circulation) framework, the priority action within the practical nurse's scope is to immediately apply oxygen to address the critical respiratory deficit and rapidly escalate the situation to the RN for advanced medical intervention.

Adım Adım Çözüm

1
Analyze the clinical cues presented by the client.
The client has sudden confusion, tachypnea, tachycardia, borderline hypotension, and hypoxia after a recent pelvic fracture.
Identifying abnormal data is the first step in clinical judgment.
2
Correlate the findings with potential physiological complications.
The combination of symptoms strongly indicates a life-threatening complication, such as fat embolism syndrome or hemorrhagic shock, leading to cerebral hypoxia.
Pelvic and long bone fractures carry a high risk for fat emboli, which peak 24 to 72 hours post-injury.
3
Prioritize interventions using the Airway, Breathing, and Circulation (ABC) framework.
Breathing and oxygenation are severely compromised (respiratory rate 26, oxygen saturation 89%).
Physiological needs related to survival always take precedence over psychosocial or comfort needs.
4
Select the most appropriate action within the PN scope of practice.
Applying oxygen addresses the immediate physiological deficit, and notifying the RN escalates care for emergent medical management.
The PN must recognize acute deterioration and initiate basic life-saving measures while seeking advanced assistance.

Anahtar Kavram

Prioritization of airway, breathing, and acute physiological deterioration recognition
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Konular

Physiological Adaptation

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