A nurse is caring for a client on the medical stepdown unit. The ...

[Anajune7]

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.

Question 2

A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best?
 
  a. It is chronic hypoxemia that accompanies restrictive airway disease.
  b. It is hypoxemia from lung damage due to mechanical ventilation.
  c. It is hypoxemia that continues even after the client is weaned from oxygen.
  d. It is hypoxemia that persists even with 100 oxygen administration.

[ryhom]

Answer to Question 1

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.

Answer to Question 2

ANS: D
Refractory hypoxemia is hypoxemia that persists even with the administration of 100 oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.