Examkin

Question

Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. The client suddenly reports sharp, pleuritic chest pain and a feeling of impending doom. The nurse obtains the following assessment data:

AssessmentFinding
Blood pressure108/84 mmHg
Heart rate122 beats/min
Respiratory rate32 breaths/min
Oxygen saturation86% on room air
pH7.52
PaCO228 mmHg
HCO324 mEq/L
PaO255 mmHg

Which of the following is the priority nursing action?

  1. Apply high-flow oxygen via a non-rebreather maskAnswer
  2. B
    Coach the client to take slow, deep breaths into a paper bag
  3. C
    Administer the prescribed intravenous morphine for chest pain
  4. D
    Request a prescription for an anxiolytic medication to manage restlessness

Answer

The correct priority action is to apply high-flow oxygen via a non-rebreather mask to treat the severe hypoxemia.
The client's presentation is highly suspicious for a pulmonary embolism, a common complication after major joint replacement surgery. The primary life-threatening issue is severe hypoxemia (PaO2 55 mmHg, SpO2 86%). According to the Airway, Breathing, Circulation (ABC) framework, maximizing oxygen delivery with a non-rebreather mask is the most urgent life-saving intervention.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client exhibits sudden chest pain, a feeling of impending doom, tachycardia, tachypnea, a narrowed pulse pressure (24 mmHg), and severe hypoxemia (SpO2 86%).
Identifying these sudden, severe changes in a postoperative client points heavily toward a life-threatening complication such as a pulmonary embolism and early compensatory shock.
2
Interpret the Arterial Blood Gas (ABG) values.
The ABG reveals uncompensated respiratory alkalosis (pH 7.52, PaCO2 28 mmHg) driven by critical hypoxemia (PaO2 55 mmHg).
The client is hyperventilating as a physiological response to compensate for the profound lack of oxygen, which consequently blows off CO2 and raises the blood pH.
3
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
Breathing and oxygenation are critically compromised and represent the most immediate threat to the client's life.
Before addressing pain or requesting medications for restlessness, the severe oxygen deficit must be corrected immediately with high-flow supplemental oxygen.

Key Concept

Prioritization in acute respiratory failure and pulmonary embolism requires immediate correction of severe hypoxemia before addressing secondary symptoms or compensatory mechanisms.
Rate this question

Topics

Physiological Adaptation

More questions from this topic