The nurse is caring for the client who is in skeletal traction for a femoral fracture and notes client assessment data includes dyspnea, hypoxia, petechial rash on chest, and hypotension. Which should the nurse implement?
1. Initiate emergency treatment measures and call provider at once.
2. Medicate the client for severe pain and re-evaluate in 30 minutes.
3. Place client in semi-Fowler's position to facilitate chest expansion.
4. Ask the client about the frequency of coughing and deep breathing.
1
1. These client data are consistent with clinical indicators for a pulmonary embolism; accordingly, the nurse institutes emergency treatment for the client to restore ade-quate oxygenation, ventilation, and perfusion and to preserve vital organ function. If the client is stable enough for transport, the health care team provides empirical treatment including supplemental oxygen, fluid resuscitation, and anticoagulation before performing diagnostic tests to determine the nature of the client's problem.
2. The client is not complaining of pain. If chest pain occurs from the pulmonary embolus, the nurse can administer morphine sulfate IV to provide pain relief but not at the expense of the respiratory rate or blood pressure.
3. Semi-Fowler's position is a reasonable nursing intervention; however, the duty the nurse owes to the client is to respond properly to changing client conditions and to prioritize nursing interventions. The most important nursing intervention is to initiate emergency care, of which positioning can be one aspect.
4. Asking the client about coughing and deep breathing is a reasonable part of a complete nursing assessment. Even though it is related to airway and breathing, it is secondary in importance to instituting emergency treatment to prevent a catastrophe.
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