Examkin

Question

Difficulty: HardPhysiological Adaptation

A client recovering from an open femoral fracture reduction abruptly develops profound dyspnea, diaphoresis, and reports a feeling of impending doom. Current vital signs are: blood pressure 85/6085/60 mmHg, heart rate 132132 bpm, respiratory rate 3434 breaths/min, and oxygen saturation 86%86\% on room air. Arterial blood gas (ABG) analysis reveals: pH 7.527.52, PaCO 2_2 2828 mmHg, PaO 2_2 5454 mmHg, and HCO 3−_3^- 2424 mEq/L. The nurse notes a rapidly narrowing pulse pressure. Which of the following is the highest priority nursing action?

  1. Apply a non-rebreather mask with oxygen at 1515 L/min and activate the rapid response team.Answer
  2. B
    Instruct the client to take slow, deep breaths into a paper bag to correct the acid-base imbalance.
  3. C
    Assist the client into a high-Fowler's position with the legs in a dependent position to improve lung expansion.
  4. D
    Prepare to administer an intravenous beta-blocker to reduce the cardiac workload and heart rate.

Answer

Apply a non-rebreather mask with oxygen at 15 L/min and activate the rapid response team.
The client is exhibiting classic signs of a massive pulmonary embolism leading to obstructive shock. The profound hypoxemia (PaO2 5454 mmHg) is the primary driver of the hyperventilation (resulting in respiratory alkalosis). Supplying high-flow oxygen addresses the most critical immediate deficit, and the rapid response team is required for advanced resuscitation, which may include intravenous fluid boluses to maintain right ventricular preload and thrombolytic therapy.

Step-by-Step Solution

1
Analyze the clinical presentation.
The client is a post-operative orthopedic patient presenting with sudden dyspnea, impending doom, hypoxia, and shock indicators (narrowing pulse pressure, hypotension).
This specific triad of symptoms in a high-risk patient strongly suggests a massive pulmonary embolism (PE) leading to obstructive shock.
2
Interpret the arterial blood gas (ABG) results.
The pH of 7.52 and PaCO2 of 28 mmHg indicate respiratory alkalosis, driven by hyperventilation. The PaO2 of 54 mmHg indicates severe, life-threatening hypoxemia.
Understanding that the alkalosis is secondary to the hypoxic drive prevents the implementation of deadly interventions, such as CO2 rebreathing.
3
Evaluate the hemodynamic status.
The blood pressure of 85/60 mmHg and heart rate of 132 bpm represent an acute state of obstructive shock caused by the embolus blocking pulmonary blood flow.
Recognizing the shock state alters standard respiratory positioning and medication protocols, prioritizing preload maintenance and cardiac output.
4
Determine the highest priority action based on the ABCs.
Maximizing oxygen delivery with a non-rebreather mask and calling for emergency assistance is selected as the paramount first step.
Airway and Breathing take absolute precedence; the client requires immediate high-flow oxygen and rapid medical intervention (e.g., fluid resuscitation, thrombolytics) to survive.

Key Concept

Recognition and emergency management of obstructive shock and severe hypoxemia secondary to a massive pulmonary embolism.
Rate this question

Topics

Physiological Adaptation

More questions from this topic