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Zorluk: ZorPhysiological Adaptation

While caring for a 76-year-old client who is two days post-open cholecystectomy, the practical nurse is informed by the unlicensed assistive personnel that the client has suddenly become restless, is picking at the bed linens, and appears disoriented. Current vital signs reveal a heart rate of 108 beats/min and a blood pressure of 102/64 mmHg. Which action should the practical nurse prioritize?

  1. Measure the client's oxygen saturation and auscultate breath soundsCevap
  2. B
    Inspect the surgical incision and abdominal dressing for signs of active bleeding
  3. C
    Inquire with visiting family members about any previous history of dementia
  4. D
    Document the current observations and recheck the vital signs in one hour

Cevap

Measure the client's oxygen saturation and auscultate breath sounds
In postoperative clients, sudden restlessness, agitation, or confusion are classic early indicators of hypoxia. The brain is extremely sensitive to decreased oxygen delivery, and these behavioral changes often precede significant drops in oxygen saturation or frank cyanosis. Because airway and breathing are the highest priorities in the ABC framework, the most immediate and critical action is to obtain a pulse oximetry reading and evaluate breath sounds to rule out respiratory compromise.

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1
Analyze the clinical presentation
The client has a sudden onset of restlessness and disorientation, paired with borderline vital signs (HR 108, BP 102/64).
Recognizing sudden changes in mental status is critical, as they are often the earliest indicators of physiological decompensation in older adults.
2
Apply the ABC (Airway, Breathing, Circulation) priority framework
Hypoxia (Breathing) must be ruled out first when acute restlessness and confusion occur.
The brain is highly sensitive to decreased oxygen levels. Restlessness is a hallmark early sign of hypoxia, making respiratory data collection the highest priority.
3
Select the nursing action that addresses the highest priority
Checking oxygen saturation directly assesses for hypoxia.
This action provides immediate, objective data regarding the client's respiratory status, guiding further emergency interventions or notification of the registered nurse.

Anahtar Kavram

Prioritization of Airway and Breathing in Acute Decompensation
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Konular

Physiological Adaptation

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