Following a transition of care report, the nurse assesses an older adult hospitalized for an acute infective exacerbation of emphysema. The client is receiving scheduled intravenous glucocorticoids and continuous nebulized bronchodilators. Which of the following clinical findings demand immediate medical notification? Select all that apply.
- The client demonstrates paradoxical inward abdominal movement during inspiration.Answer
- The cardiac monitor displays a new onset of frequent premature ventricular contractions.Answer
- The client becomes newly agitated and repeatedly attempts to remove the oxygen mask.Answer
- DArterial blood gas values indicate a pH of 7.36, PaCO2 of 54 mm Hg, and HCO3 of 31 mEq/L.
- EThe client exhibits fine, bilateral resting tremors in the hands.
- FThe anterior-posterior diameter of the client's chest equals the transverse diameter.
Answer
The findings requiring immediate notification are paradoxical abdominal breathing, new onset of frequent premature ventricular contractions, and newly developed agitation with attempts to remove the oxygen mask.
The correct selections highlight acute deteriorations that threaten Airway, Breathing, and Circulation (ABCs). Paradoxical abdominal breathing indicates severe respiratory muscle fatigue and impending respiratory failure. A new onset of dysrhythmias suggests profound cardiac hypoxemia or potential medication toxicity. Increasing agitation and attempts to remove the oxygen source are classic early behavioral indicators of worsening systemic hypoxia that demand immediate, life-saving intervention.
Step-by-Step Solution
Key Concept
Prioritization in respiratory compromise requires distinguishing between acute, life-threatening changes (e.g., paradoxical breathing, hypoxia-induced restlessness, new dysrhythmias) and expected chronic manifestations or pharmacological side effects (e.g., compensated respiratory acidosis, barrel chest, bronchodilator-induced tremors).