Examkin

Soru

Zorluk: Çok zorPhysiological Adaptation

During morning rounds, a practical nurse evaluates a client who underwent an open reduction and internal fixation of a fractured right femur 24 hours ago. The client, who is 85 years old, suddenly becomes highly agitated and attempts to pull out their intravenous line. Physical assessment reveals scattered petechiae over the client's anterior chest. Current vital signs are: heart rate 118 beats per minute, respiratory rate 28 breaths per minute, oxygen saturation 88% on room air, and blood pressure 104/68 mm Hg. The client's preoperative baseline blood pressure was 138/82 mm Hg. Which immediate actions should the practical nurse take? Select all that apply.

  1. Contact the rapid response team and the supervising registered nurse immediately.Cevap
  2. Initiate supplemental oxygen administration according to standing emergency protocols.Cevap
  3. Intervene to protect and secure the client's existing intravenous access line.Cevap
  4. D
    Reassure the family that sudden disorientation is a normal, expected reaction to orthopedic surgery in older adults.
  5. E
    Administer the prescribed as-needed oral opioid analgesic to address potential uncontrolled pain causing the agitation.
  6. F
    Document the current vital signs and continue monitoring, as the systolic blood pressure remains relatively stable above 100 mm Hg.

Cevap

The correct actions are to contact the rapid response team, initiate supplemental oxygen, and secure the client's intravenous access.
The client is exhibiting the classic triad of Fat Embolism Syndrome (FES) following a long bone fracture: hypoxia (agitation, tachypnea, low oxygen saturation), neurologic abnormalities, and a petechial rash. This is a life-threatening emergency. The practical nurse must immediately prioritize Airway and Breathing by applying oxygen, protect the intravenous line for imminent resuscitation needs, and activate the rapid response team for advanced medical intervention.

Adım Adım Çözüm

1
Analyze the client's postoperative presentation and vital signs.
The client demonstrates sudden agitation, severe hypoxia, tachypnea, tachycardia, relative hypotension, and a petechial rash on the chest.
Identifying abnormal, acute assessment findings is the first step in recognizing a life-threatening physiological adaptation failure.
2
Correlate the assessment findings with the recent surgical history.
A recent long bone fracture repair combined with hypoxia, altered mental status, and petechiae indicates Fat Embolism Syndrome (FES), a medical emergency.
FES is a specific, high-risk complication of long bone fractures that requires immediate aggressive intervention.
3
Determine the practical nurse's priority interventions based on the Airway, Breathing, Circulation (ABC) framework.
The practical nurse must immediately support breathing by applying oxygen, protect the IV line for circulatory support, and activate the rapid response team.
The practical nurse is responsible for initiating basic life-saving measures and rapidly escalating care to the registered nurse and provider when a client becomes unstable.

Anahtar Kavram

Recognizing early signs of Fat Embolism Syndrome (FES) and prioritizing ABCs and rapid escalation of care.
Bu soruyu puanla

Konular

Physiological Adaptation

Bu konudan daha fazla soru