Examkin

Question

Difficulty: MediumPhysiological Adaptation

An adult client who underwent an open reduction and internal fixation of the right femur 48 hours ago suddenly develops extreme restlessness and shortness of breath. The nurse assesses the client and records the following vital signs: temperature 37.4°C (99.3°F), heart rate 126 beats/min, respirations 32 breaths/min, and blood pressure 114/72 mm Hg. The oxygen saturation is 85% on room air. A stat arterial blood gas (ABG) reveals a pH of 7.52, PaCO2 of 28 mm Hg, PaO2 of 53 mm Hg, and HCO3- of 23 mEq/L. Based on these findings, what is the priority nursing action?

  1. A
    Instruct the client to take slow, deep breaths into a paper bag to correct the respiratory pattern.
  2. Apply a high-concentration oxygen delivery device and activate the rapid response team.Answer
  3. C
    Administer the prescribed intravenous sodium bicarbonate and prepare for endotracheal intubation.
  4. D
    Position the client supine with legs elevated and increase the continuous intravenous fluid infusion rate.

Answer

The priority is to apply a high-concentration oxygen delivery device and activate the rapid response team.
The clinical picture of acute-onset restlessness, severe hypoxia, and uncompensated respiratory alkalosis in a post-operative long bone fracture client strongly suggests a life-threatening pulmonary or fat embolism. The priority is to immediately address the profound hypoxemia with high-flow oxygen and activate the rapid response team to escalate medical management.

Step-by-Step Solution

1
Analyze the clinical presentation and context.
The client is 48 hours post-femur fracture repair and presents with acute-onset restlessness, tachypnea, tachycardia, and severe hypoxia, suggesting a pulmonary embolism or fat embolism.
Identifying the likely etiology guides the urgency and type of intervention required.
2
Interpret the arterial blood gas (ABG) results.
pH 7.52 (alkalosis), PaCO2 28 mm Hg (low, indicating respiratory cause), PaO2 53 mm Hg (severe hypoxemia), HCO3- 23 mEq/L (normal). Interpretation: Uncompensated respiratory alkalosis with severe hypoxemia.
Accurate ABG interpretation distinguishes between primary respiratory failure, compensatory hyperventilation, and metabolic disturbances.
3
Determine the priority nursing intervention based on the physiological data.
The respiratory alkalosis is a compensatory response to the life-threatening hypoxemia. The immediate need is to restore oxygenation and escalate care.
Addressing the root cause of the compromised airway and breathing takes precedence according to the ABC (Airway, Breathing, Circulation) framework.

Key Concept

Prioritization of care for acute hypoxemic respiratory failure and uncompensated respiratory alkalosis related to a suspected pulmonary or fat embolism.
Rate this question

Topics

Physiological Adaptation

More questions from this topic