An unresponsive patient is brought to the emergency department by ambulance personnel who have been performing CPR. Arterial blood gas results reveal the following: pH 7.225, PaCO2 55, HCO3 15, PaO2 45, SaO2 76 percent

Question

Based on the patient's history, the nurse should prepare for which of the following interventions first? 1. calling a code
2. assisting with endotracheal intubation
3. performing a complete head-to-toe assessment
4. placing the patient on a 50 percent humidified mask

Answer 1

2

Rationale: The patient is unresponsive. Based on the blood gas results, it is obvious that the patient is suffering from acute ventilatory failure and is in urgent need of intubation and mechanical ventilation. Because this type of scenario is common in an emergency department and personnel are available, one would not necessarily call a code. Although a head-to-toe assessment will be in order at some point, it is not the immediate priority. A humidified mask will not be effective for the patient who is not ventilating effectively.