Which assessment finding in a client in the refractory phase of shock requires immediate nursing intervention?

A. Fatigue without a feveris correct because older adults often have a blunted immune and inflammatory response. They may not develop a fever even in severe infection or septic shock. Instead, they commonly present with nonspecific symptoms such as weakness, fatigue, or malaise.

B. Weakened respirationsis correct because aging is associated with decreased lung elasticity, reduced chest wall expansion, and weaker respiratory muscles. In shock, older adults may not mount a strong tachypneic response and can demonstrate shallow or weakened respirations.

C. Normal sinus rhythmis incorrect because shock typically triggers compensatory tachycardia. However, in older adults, especially those taking medications such as beta blockers, the heart rate response may be blunted. A completely normal sinus rhythm is not considered a characteristic finding of shock; altered or inadequate compensatory responses are more typical.

D. Decreased clarity of thinkingis correct because altered mental status is often one of the earliest and most significant signs of shock in older adults. Reduced cerebral perfusion leads to confusion, restlessness, agitation, or lethargy.

E. Adequate urinary outputis incorrect because shock results in decreased renal perfusion, leading to reduced urinary output (oliguria). Adequate urine output would not be expected in a client experiencing shock.

A. Assess the nasal cannula for proper placement and any kinks or obstructionsis correct because before making any changes to oxygen therapy or administering medications, the nurse must first ensure that the oxygen delivery device is functioning correctly. Incorrect placement, tubing disconnections, or kinks can reduce oxygen delivery and cause hypoxemia. This assessment is the safest and most immediate actionto identify a reversible cause of low SpO2.

B. Encourage the patient to take deep breaths and cough to clear secretionsis incorrect as the initial action because while coughing and deep breathing can improve oxygenation over time, it does not address the immediate potential mechanical issuewith oxygen delivery that could be causing the low saturation.

C. Administer a short-acting bronchodilator inhaler as orderedis incorrect because this should only be done after assessing for mechanical or reversible causesof hypoxemia. While bronchodilators help relieve airway constriction in COPD, they do not immediately correct problems related to oxygen delivery device malfunction.

D. Increase the oxygen flow rate to 4 LPM to improve oxygenationis incorrect as the initial action in a COPD patient because rapid increases in oxygen can suppress the patient’s respiratory drivein chronic CO2 retainers. Any adjustment to oxygen flow must be done safely and after assessing equipment and patient response.