The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal statement is the highest priority for the nurse to include in the patient's care plan for the diagnosis Impaired gas exchange r/t impaired pulmonary blood flow from embolus?
a. The patient will maintain pulse oximetry values of at least 95% on room air.
b. The patient will verbalize understanding of ordered anticoagulants.
c. The patient will report chest pain of no greater than 3 on a 1-10 scale.
d. The patient will ambulate 50 feet in hallway without shortness of breath.
ANS: A
Oxygenation is the most important human need, so adequate oxygenation of tissues as evidenced by pulse oximetry values of at least 95% on room air is the highest priority goal. The other goals may be addressed once the oxygenation goal has been met.
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