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Zorluk: ZorPhysiological Adaptation

At the start of the shift, a practical nurse observes a 77-year-old client who is hospitalized for conservative management of a pelvic fracture. The client, who was previously lucid and conversant, is now restless, pulling at their intravenous tubing, and speaking incoherently. Current vital signs reveal a heart rate of 115 beats/minute, respirations of 26 breaths/minute, and a blood pressure of 94/58 mm Hg. Based on these findings, which of the following is the priority action for the practical nurse?

  1. Obtain an oxygen saturation reading, elevate the head of the bed, and immediately alert the supervising registered nurse.Cevap
  2. B
    Implement strict fall precautions by activating the bed alarm and instructing the unlicensed assistive personnel to remain in the room.
  3. C
    Reorient the client to the hospital environment and perform a bladder scan to check for urinary retention.
  4. D
    Document the vital signs and continue scheduled monitoring, as the blood pressure remains within an acceptable adult range.

Cevap

The correct action is to prioritize respiratory assessment (oxygen saturation), position the client to facilitate optimal breathing, and urgently escalate the physiological changes to the registered nurse.
Acute confusion, tachycardia, tachypnea, and borderline hypotension in a client with a major bone fracture are classic early signs of a severe physiological complication, such as a fat embolism or hemorrhagic shock. According to the ABC (Airway, Breathing, Circulation) framework, the practical nurse must first assess oxygenation, support breathing by elevating the head of the bed, and immediately notify the registered nurse for advanced collaborative interventions.

Adım Adım Çözüm

1
Analyze the client's clinical presentation.
The client exhibits acute mental status changes, tachycardia (115 beats/minute), tachypnea (26 breaths/minute), and borderline hypotension.
Identifying sudden changes from a previously stable baseline is essential for early recognition of life-threatening complications.
2
Correlate the assessment findings with the admitting diagnosis.
A pelvic fracture places the client at high risk for severe complications such as fat embolism syndrome or internal hemorrhagic shock.
Understanding diagnostic risk factors helps differentiate between expected aging-related hospital delirium and a physiological medical emergency.
3
Apply the Airway-Breathing-Circulation (ABC) priority framework.
The elevated respiratory rate and heart rate suggest a cardiopulmonary crisis (hypoxia or shock), making oxygenation assessment and immediate registered nurse notification the absolute highest priorities.
Acute physiological instability always takes precedence over psychosocial interventions, basic safety measures, or routine monitoring.

Anahtar Kavram

Early recognition of shock or fat embolism syndrome in clients with major fractures requires prioritizing the ABC framework over basic safety or reorientation.
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Physiological Adaptation

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