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Question

Difficulty: MediumReduction of Risk Potential

While conducting hourly rounds on a surgical unit, a nurse encounters a client who is two days post-operative from an open bowel resection. The client is extremely restless, clutching their chest, and gasping for air. The bedside monitor displays a heart rate of 124 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 90/62 mm Hg, and an oxygen saturation of 84% on room air. The rapid response team is activated, and immediate arterial blood gas (ABG) results show a pH of 7.52, PaCO2 of 28 mm Hg, PaO2 of 54 mm Hg, and HCO3 of 23 mEq/L. Which of the following actions should the nurse execute first to mitigate the risk of cardiopulmonary arrest?

  1. Apply oxygen via a non-rebreather mask and elevate the head of the bed to a high-Fowler's position.Answer
  2. B
    Initiate a continuous intravenous infusion of sodium bicarbonate to reverse uncompensated respiratory acidosis.
  3. C
    Position the client flat on their back and elevate their lower extremities to treat anticipated hypovolemic shock.
  4. D
    Assess the surgical site for occult hemorrhage by deeply palpating all four abdominal quadrants prior to auscultation.

Answer

The priority action is to apply oxygen via a non-rebreather mask and elevate the head of the bed to a high-Fowler's position.
The correct action directly addresses the client's most critical, life-threatening problem: severe hypoxemia and respiratory compromise (likely secondary to a pulmonary embolism). Utilizing the ABCs (Airway, Breathing, Circulation) framework, optimizing oxygen delivery via a non-rebreather mask and facilitating maximum lung expansion by elevating the head of the bed are the absolute highest priorities to prevent cardiopulmonary arrest.

Step-by-Step Solution

1
Analyze the clinical presentation and vital signs.
The client is experiencing acute, severe respiratory distress, hypoxia (SpO2 84%), tachycardia, and chest pain, which are hallmark indicators of a potential pulmonary embolism.
Identifying the primary physiological failure guides immediate prioritization.
2
Interpret the arterial blood gas (ABG) values.
pH 7.52 (alkaline), PaCO2 28 mm Hg (low, respiratory origin), and HCO3 23 mEq/L (normal) indicate uncompensated respiratory alkalosis, accompanied by severe hypoxemia (PaO2 54 mm Hg).
Accurate ABG interpretation confirms the client is hyperventilating to compensate for profound hypoxia, ruling out acidosis.
3
Apply the ABC (Airway, Breathing, Circulation) prioritization framework.
The most critical, life-threatening deficit is oxygenation. Supplying high-flow oxygen and optimizing anatomical positioning for lung expansion (high-Fowler's) are the immediate required actions.
Airway and breathing interventions must always precede circulation interventions or further diagnostic assessments when a client is actively decompensating.

Key Concept

Prioritization of oxygenation and correct positioning for acute respiratory distress, coupled with accurate ABG interpretation.
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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