A client who was extubated 2 hours ago is becoming increasingly restless. The last vital signs before extubation were pulse 88 beats/min, respirations 18 breaths/min, blood pressure mm Hg, and PaCO2 45 mm Hg
Current vital signs include pulse 104 beats/min, respirations 26 breaths/min, blood pressure mm Hg, and PaCO2 62 mm Hg. The nurse would a. administer a nebulized bronchodilator.
b. assist with reintubation.
c. obtain a complete blood count (CBC).
d. prepare the client for a tracheostomy.
B
The nurse should assess the client for indications of respiratory distress and hypoxemia, as evidenced by restlessness, irritability, tachycardia, tachypnea, and decreased PaO2 or increased PaCO2 . If these manifestations are noted, the nurse should notify the physician and prepare for reintubation.
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