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Difficulty: MediumPhysiological Adaptation

At 0800, a nurse responds to a monitoring alarm for an adult client who is 36 hours post-operative from an open reduction and internal fixation of a fractured right femur. The client appears highly restless, confused, and is expectorating small amounts of blood-tinged sputum. Vital signs reveal a heart rate of 126 beats/min, a respiratory rate of 34 breaths/min, blood pressure of 148/88 mm Hg, and an oxygen saturation of 84% on room air. An arterial blood gas (ABG) analysis indicates a pH of 7.53, PaCO2 of 27 mm Hg, HCO3 of 23 mEq/L, and PaO2 of 52 mm Hg. Which intervention is the priority for the nurse to implement?

  1. Apply a non-rebreather oxygen mask at 15 L/min.Answer
  2. B
    Coach the client to take slow, deep breaths to lower the respiratory rate.
  3. C
    Administer the prescribed intravenous morphine sulfate to manage the client's agitation.
  4. D
    Notify the imaging department to prepare the client for a STAT pulmonary angiogram.

Answer

Apply a non-rebreather oxygen mask at 15 L/min.
The correct answer directly addresses the most immediate threat to the client's life: severe hypoxemia (PaO2 of 52 mm Hg). The client's restlessness, confusion, and rapid breathing are compensatory mechanisms for this profound lack of oxygen, likely resulting from a fat embolism or pulmonary embolism after the femur fracture. Based on the ABC (Airway, Breathing, Circulation) framework, restoring oxygenation with high-flow supplemental oxygen is the absolute highest priority.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) results and pulse oximetry.
The client has uncompensated respiratory alkalosis (high pH, low PaCO2) with severe hypoxemia (PaO2 52 mm Hg, SpO2 84%).
To identify the primary physiological derangement causing the acute symptoms.
2
Evaluate the clinical presentation in the context of the client's surgical history.
The client is restless, tachypneic, tachycardic, and has blood-tinged sputum 36 hours after a long bone fracture, strongly suggesting a fat embolism syndrome or pulmonary embolism.
To correlate the laboratory values with the physical symptoms of acute respiratory distress.
3
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
Oxygenation must be addressed immediately before moving to symptom management or diagnostic testing.
To determine the single most critical and immediate nursing action to prevent physiological collapse.

Key Concept

Prioritizing oxygenation in acute hypoxemic respiratory failure
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Topics

Physiological Adaptation

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