During morning rounds, the nurse assesses a client recovering from an anterior wall myocar… — NCLEX-RN

During morning rounds, the nurse assesses a client recovering from an anterior wall myocardial infarction sustained two days prior. The client suddenly expresses intense anxiety and a feeling of suffocation. Auscultation reveals bilateral basilar crackles, and the client's skin is cool and diaphoretic.

The most recent clinical parameters are as follows:

Parameter	Value
Blood Pressure	$94/78$ mm Hg
Heart Rate	$118$ beats/min
Respiratory Rate	$28$ breaths/min
pH	$7.50$
$PaCO_2$	$28$ mm Hg
$PaO_2$	$59$ mm Hg
$HCO_3^-$	$22$ mEq/L

Which of the following is the highest priority nursing intervention?

Elevate the head of the bed and apply supplemental oxygen.Answer
B
Initiate a rapid intravenous bolus of 0.9% sodium chloride.
C
Coach the client to perform slow, pursed-lip breathing.
D
Obtain a stat 12-lead electrocardiogram.

Answer

The correct response is to elevate the head of the bed and apply supplemental oxygen.

The client is experiencing acute pulmonary edema and early cardiogenic shock, as evidenced by the anterior myocardial infarction history, basilar crackles, narrow pulse pressure, and severe hypoxemia. The immediate priority is to support the ABCs (Airway, Breathing, Circulation). Elevating the head of the bed decreases venous return (preload) to the failing heart and maximizes lung expansion, while supplemental oxygen directly treats the life-threatening hypoxemia.

Step-by-Step Solution

Analyze the clinical presentation and vital signs.

The client has crackles, cold/diaphoretic skin, tachycardia, and a narrow pulse pressure of 16 mm Hg following an anterior myocardial infarction.

To identify the underlying complication, which is cardiogenic shock and acute pulmonary edema.

Interpret the arterial blood gas values.

The ABG indicates uncompensated respiratory alkalosis secondary to severe hypoxemia, as evidenced by a PaO2 of 59 mm Hg.

To determine the client's respiratory status and recognize that the hyperventilation is driven by an urgent need for tissue oxygenation.

Prioritize nursing interventions using the ABC (Airway, Breathing, Circulation) framework.

Positioning the client upright and providing oxygen directly address the compromised breathing and profound hypoxemia.

Immediate stabilization of gas exchange is the highest life-saving priority before performing diagnostic tests or addressing other secondary symptoms.

Key Concept

Prioritization of care in cardiogenic shock and acute pulmonary edema requires immediate stabilization of airway and breathing through upright positioning and supplemental oxygen.

Question

Answer

Step-by-Step Solution

Key Concept

Common Mistakes

Topics

More questions from this topic