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Question

Difficulty: MediumPhysiological Adaptation

A nurse is caring for a client who is two days postoperative following a right total knee arthroplasty. The client suddenly reports sharp, pleuritic chest pain, severe shortness of breath, and a feeling of impending doom. The client appears diaphoretic and highly agitated. Arrange the following nursing actions in the priority order they should be performed. (Place the first action at the top and the last action at the bottom.)

  1. 1Elevate the head of the bed to a high-Fowler's position.
  2. 2Apply high-flow supplemental oxygen via a non-rebreather mask.
  3. 3Obtain a complete set of vital signs, including oxygen saturation.
  4. 4Notify the rapid response team and the healthcare provider.
  5. 5Establish a secondary peripheral intravenous access line.

Answer

The correct priority sequence is to first elevate the head of the bed, then apply oxygen, obtain vital signs, notify the rapid response team, and finally establish secondary intravenous access.
The correct sequence prioritizes immediate, non-invasive airway and breathing interventions (elevating the head of the bed and applying oxygen) because they take seconds to perform and immediately address the life-threatening hypoxia. Once the client's breathing is mechanically supported, the nurse must assess the client's physiological status (vital signs) to gather the necessary data before communicating with the rapid response team. Finally, preparing for advanced medical interventions (establishing IV access) is done once help is on the way.

Step-by-Step Solution

1
Recognize the clinical signs of a pulmonary embolism (sudden dyspnea, pleuritic pain, impending doom) as an acute respiratory emergency.
The client is identified as requiring immediate life-saving interventions.
Failure to act promptly on signs of acute respiratory compromise can lead to respiratory failure and cardiac arrest.
2
Elevate the head of the bed to a high-Fowler's position.
The diaphragm drops, allowing for maximal chest expansion.
This is the most rapid intervention to decrease the work of breathing and improve ventilation mechanics.
3
Apply high-flow supplemental oxygen.
Alveolar oxygen concentration rapidly increases.
This treats the severe hypoxemia caused by the ventilation-perfusion mismatch associated with a pulmonary embolus.
4
Obtain a complete set of vital signs, including oxygen saturation.
Baseline physiological and hemodynamic data is established.
This quantitative data is required to determine the severity of the compromise and to accurately report the client's status to the provider.
5
Notify the rapid response team and healthcare provider.
Advanced medical support and specialized orders are obtained.
The client requires diagnostic testing and medical interventions (such as anticoagulation) that require a provider's order.
6
Establish a secondary peripheral intravenous access line.
A dedicated venous line is available for emergency administration.
The client will likely require fluid resuscitation, vasopressors, or continuous anticoagulation infusions to manage the crisis.

Key Concept

In an acute respiratory emergency, nursing priorities follow the airway, breathing, circulation (ABC) framework and the nursing process: intervene immediately to support airway/breathing, assess to gather data, communicate findings, and prepare for advanced medical management.
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Topics

Physiological Adaptation

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