A nurse is caring for a client who sustained a closed transverse femur fracture 36 hours ago. The client suddenly becomes highly agitated, reports a feeling of impending doom, and is experiencing severe dyspnea. The nurse notes the appearance of a petechial rash over the client's anterior chest and neck. An arterial blood gas (ABG) analysis is obtained while the client is breathing room air, revealing the following results: pH 7.48, 29 mm Hg, 54 mm Hg, and 23 mEq/L. What is the priority nursing action?
- Apply high-flow oxygen via a non-rebreather mask.Cevap
- BInstruct the client to take slow, deep breaths to slow their respiratory rate.
- CInitiate a rapid intravenous fluid bolus of normal saline.
- DPrepare to administer an intravenous dose of a thrombolytic agent.
Cevap
The priority action is to apply high-flow oxygen via a non-rebreather mask to address the severe, life-threatening hypoxemia caused by Fat Embolism Syndrome.
The correct answer directly addresses the client's most critical physiological deficit: severe hypoxemia resulting from a fat embolism. Recognizing the triad of FES (hypoxemia, neurological abnormalities, and petechiae) and understanding that the ABG reflects compensatory hyperventilation points to oxygen administration as the undisputed first priority.
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Anahtar Kavram
Fat Embolism Syndrome (FES) Recognition and Acute Oxygenation