A nurse is caring for a client on the medical stepdown unit. The following data are related to this client:
Subjective Information
Laboratory Analysis
Physical Assessment
Shortness of breath for 20 minutes
Feels frightened
"Can't catch my breath"
pH: 7.12
PaCO2: 28 mm Hg
PaO2: 58 mm Hg
SaO2: 88%
Pulse: 120 beats/min
Respiratory rate: 34 breaths/min
Blood pressure 158/92 mm Hg
Lungs have crackles
What action by the nurse is most appropriate?
a.
Call respiratory therapy for a breathing treatment.
b.
Facilitate a STAT pulmonary angiography.
c.
Prepare for immediate endotracheal intubation.
d.
Prepare to administer intravenous anticoagulants.
ANS: B
This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the client's presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of PE.
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