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Difficulty: Very hardReduction of Risk Potential

A 70-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) is hospitalized for treatment of a left lower extremity deep vein thrombosis. The client suddenly develops sharp, pleuritic chest pain, severe dyspnea, and profound apprehension.

Current Assessment and Laboratory Data:
- Vital Signs: BP 94/60 mmHg (baseline 135/82), HR 122 bpm, RR 32/min, Temperature 98.9°F (37.2°C).
- SpO2: 84% on 2 L/min oxygen via nasal cannula.
- Skin: Pale, diaphoretic, with circumoral cyanosis.
- Arterial Blood Gas (ABG):
- pH: 7.54
- PaCO2: 28 mmHg (baseline 55 mmHg)
- HCO3-: 26 mEq/L
- PaO2: 52 mmHg

The nurse suspects an acute pulmonary embolism. To reduce the client's risk for immediate cardiopulmonary collapse, which of the following is the most critical initial action?

  1. Increase oxygen delivery to 15 L/min via a non-rebreather mask and immediately activate the rapid response team.Answer
  2. B
    Administer a prescribed short-acting bronchodilator via nebulizer and assist the client with pursed-lip breathing.
  3. C
    Coach the client to breathe slowly into a paper bag to correct the uncompensated respiratory alkalosis.
  4. D
    Maintain the current oxygen flow rate to avoid suppressing the hypoxic drive, and position the client flat with legs elevated to improve venous return.

Answer

Increase oxygen delivery to 15 L/min via a non-rebreather mask and immediately activate the rapid response team.
The client is exhibiting classic signs of an acute pulmonary embolism leading to early obstructive shock and severe hypoxemia. Despite the client's history of COPD, where high-flow oxygen is typically used with caution, acute life-threatening hypoxemia (PaO2 52 mmHg, SpO2 84%) mandates immediate administration of 100% oxygen via a non-rebreather mask. The risk of cardiac arrest from profound hypoxemia far outweighs the theoretical risk of suppressing the hypoxic drive. The rapid response team must be activated immediately to manage the impending cardiopulmonary collapse.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client exhibits sudden severe dyspnea, pleuritic chest pain, hypoxia, tachycardia, and hypotension following a DVT, which strongly indicates a pulmonary embolism.
Identifying the underlying medical emergency is essential to determine the priority intervention.
2
Interpret the Arterial Blood Gas (ABG) results.
The ABG shows uncompensated respiratory alkalosis (high pH, low PaCO2) and severe hypoxemia (PaO2 52 mmHg).
This confirms that the client is hyperventilating to compensate for the profound lack of oxygen, ruling out a standard COPD exacerbation (which would present with respiratory acidosis).
3
Determine the highest priority intervention to reduce physiological risk.
Administering high-flow oxygen and calling for emergency assistance is the absolute priority.
Airway and Breathing take precedence. Severe hypoxemia will quickly lead to cardiopulmonary arrest. The theoretical risk of suppressing the hypoxic drive in COPD is superseded by the immediate need to treat lethal hypoxemia.

Key Concept

Prioritization in Pulmonary Embolism and Acute Hypoxemia
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Topics

Reduction of Risk Potential

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