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Difficulty: HardReduction of Risk Potential

A 72-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) is evaluated in the emergency department for a suspected respiratory infection. The client appears increasingly restless. Current vital signs are: blood pressure 104/82 mm Hg104/82\text{ mm Hg}, heart rate 116 beats/min116\text{ beats/min}, respiratory rate 28 breaths/min28\text{ breaths/min}, temperature 101.8∘F101.8^\circ\text{F} (38.8∘C38.8^\circ\text{C}), and oxygen saturation 86%86\% on room air. To reduce the risk of further physiological decompensation, which of the following actions should the nurse include in the immediate plan of care? Select all that apply.

  1. Administer a prescribed intravenous bolus of 0.9%0.9\% sodium chloride to restore vascular volume.Answer
  2. Administer prescribed intravenous broad-spectrum antibiotics immediately after obtaining blood cultures.Answer
  3. Apply supplemental oxygen using a Venturi mask to target an oxygen saturation of 88%88\% to 92%92\%.Answer
  4. D
    Lower the head of the bed to a flat, supine position to increase venous return to the heart.
  5. E
    Withhold all supplemental oxygen until a baseline arterial blood gas (ABG) sample is drawn to avoid eliminating the hypoxic drive.
  6. F
    Attribute the narrowing pulse pressure and tachycardia to the client's fever and continue routine monitoring.

Answer

The correct actions are administering a prescribed intravenous fluid bolus, administering antibiotics after obtaining blood cultures, and applying precise oxygen via a Venturi mask.
The correct answers prioritize immediate stabilization of the client's airway, breathing, and circulation. Applying a Venturi mask targets safe oxygenation for a client with COPD. Isotonic fluid resuscitation and prompt antibiotic administration following blood cultures are critical early interventions to halt the progression of septic shock, which is indicated by the client's restlessness, tachycardia, and narrowing pulse pressure.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs.
The client exhibits severe hypoxemia (SpO2SpO_2 86%86\%), tachypnea, tachycardia, and a narrowing pulse pressure (104/82 mm Hg104/82\text{ mm Hg}).
Identifying abnormal findings is necessary to determine the imminent risk of physiological decompensation.
2
Identify the underlying physiological risks.
The assessment data indicates acute respiratory failure complicated by early compensatory septic shock.
Accurate recognition of life-threatening conditions dictates the priority of nursing interventions.
3
Select interventions that safely address both respiratory failure and early shock.
Appropriate actions include administering controlled oxygen via a Venturi mask, initiating IV fluid resuscitation, and giving antibiotics after obtaining blood cultures.
These combined actions stabilize the cardiopulmonary system and treat the underlying infection without causing harm.

Key Concept

Early recognition and intervention for septic shock and severe hypoxemia in clients with chronic pulmonary conditions.
Estimated Time:2m 30s
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Topics

Reduction of Risk Potential

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