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Zorluk: OrtaPhysiological Adaptation

A client on an orthopedic unit is three days postoperative following a unilateral knee replacement. The client suddenly reports sharp, localized chest pain upon inspiration accompanied by a feeling of impending doom. Current vital signs reveal a respiratory rate of 32 breaths per minute and an oxygen saturation of 85% on room air. Which of the following concurrent nursing actions are appropriate? Select all that apply.

  1. Position the head of the bed at a 60- to 90-degree angleCevap
  2. Apply supplemental oxygen using a high-flow delivery deviceCevap
  3. Notify the facility's rapid response or emergency medical teamCevap
  4. D
    Withhold oxygen therapy until a baseline arterial blood gas sample is drawn
  5. E
    Assign unlicensed assistive personnel to monitor continuous pulse oximetry readings
  6. F
    Transition the client into a left lateral Trendelenburg position

Cevap

The correct actions involve elevating the head of the bed, applying supplemental oxygen immediately, and activating the rapid response team.
The client is exhibiting classic signs of an acute pulmonary embolism, a life-threatening medical emergency commonly associated with immobility following major orthopedic surgery. Immediate nursing priorities must focus on optimizing oxygenation and ventilation. Elevating the head of the bed maximizes diaphragmatic excursion and lung expansion. Applying high-flow oxygen directly addresses the severe hypoxia. Because the client is rapidly decompensating and unstable, activating the rapid response team is a critical simultaneous action to secure advanced airway management and initiate hemodynamic support or anticoagulation.

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1
Analyze the client's postoperative timeline, sudden onset of pleuritic pain, and acute respiratory distress.
Identify that the clinical presentation strongly suggests an acute pulmonary embolism.
Recognizing the underlying life-threatening pathology dictates immediate and appropriate action.
2
Apply the Airway, Breathing, Circulation (ABC) prioritization framework.
Determine that oxygenation and ventilation are the highest priority needs.
The client's hypoxia is severe (85% on room air) and requires immediate reversal to prevent tissue ischemia and cardiovascular collapse.
3
Select interventions that stabilize the client and escalate care concurrently.
Identify high-Fowler's positioning, high-flow oxygen administration, and rapid response activation as the correct simultaneous priorities.
These actions address the immediate physiological crisis while bringing necessary advanced medical support to the bedside.

Anahtar Kavram

Immediate Nursing Management of Acute Pulmonary Embolism
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Konular

Physiological Adaptation

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