Oxygenation
A client with COPD becomes somnolent after an opioid. Respirations fall from 24 to 10/min, pH is 7.24, and PaCO2 is 72 mm Hg. This problem best explains the change from baseline.
What is acute hypoventilation with respiratory acidosis?
A chest drainage system shows continuous bubbling in the water-seal chamber after the initial postoperative period. This system problem should be investigated.
What is an air leak?
Calf discomfort begins predictably with walking and resolves with rest. The foot is cool with diminished pulses and shiny skin. This vascular problem best fits the pattern.
What is peripheral arterial disease with intermittent claudication?
Substernal pressure occurs at the same workload, lasts several minutes, and resolves with rest. This pattern is most consistent with this coronary syndrome.
What is stable angina?
A client with chest pain has a nitroglycerin prescription and reports using sildenafil earlier that day. This is the nurse's next action.
What is hold the nitrate and immediately clarify the plan?
During treatment of severe asthma, wheezing becomes faint while retractions increase and the client can speak only one word at a time. This interpretation is most concerning.
What is worsening airflow obstruction with impending respiratory failure?
Tidaling suddenly stops. The client is comfortable, breath sounds are improving, and the tubing has no dependent loops. This possibility should be assessed before assuming obstruction.
What is lung re-expansion?
A postoperative client has new unilateral calf swelling, warmth, and tenderness. This condition is the priority hypothesis.
What is deep vein thrombosis?
Sharp chest pain worsens when supine and improves while leaning forward; a friction rub and diffuse ST-segment elevation are present. This diagnosis fits the cluster.
What is acute pericarditis?
Before a scheduled digoxin dose, the apical pulse is 52/min and potassium is 3.0 mEq/L. This response is safest.
What is hold digoxin, assess for toxicity, and notify the provider?
Two days after hip surgery, a client develops sudden dyspnea, pleuritic chest pain, tachycardia, and new hypoxemia with clear lung fields. This diagnosis is most likely.
What is pulmonary embolism?
A chest tube becomes disconnected from the drainage unit. This immediate nursing action limits air entry while a new sterile system is prepared.
What is place the tube end in sterile water according to emergency protocol?
An older adult with a known abdominal aortic aneurysm develops sudden back pain, diaphoresis, hypotension, and a rapidly expanding abdominal mass. This complication is most likely.
What is rupturing abdominal aortic aneurysm?
Orthopnea, crackles, an S3, and pink frothy sputum reflect failure of this side of the heart and resulting pulmonary congestion.
What is left-sided heart failure?
After femoral cardiac catheterization, the affected foot becomes cool and pale with a newly absent pedal pulse. This complication requires immediate reporting.
What is acute arterial perfusion impairment?
A client with sepsis has bilateral opacities, severe hypoxemia that persists despite supplemental oxygen, and no evidence that left-sided heart failure explains the edema. This syndrome fits the pattern.
What is acute respiratory distress syndrome, or ARDS?
A mechanically ventilated client suddenly becomes hypotensive. Peak airway pressure rises, the trachea shifts, and breath sounds are absent on one side. This emergency is most likely.
What is tension pneumothorax?
After adequate initial fluid resuscitation for sepsis, MAP remains low and lactate continues to rise while the skin is warm. This hemodynamic problem remains.
What is distributive shock requiring vasopressor support?
Jugular venous distention, dependent edema, hepatomegaly, and weight gain occur without new pulmonary crackles. This hemodynamic pattern is most likely.
What is right-sided heart failure?
After aggressive diuresis for heart failure, weight and edema decrease, but creatinine rises and orthostatic symptoms appear. This assessment should guide the next treatment decision.
What is reassess intravascular volume and renal perfusion?
A client with pneumonia remains tachypneic at 36/min, but PaCO2 rises from 30 to 48 mm Hg while mental status declines. This trend signals the change in respiratory status.
What is respiratory muscle fatigue with developing ventilatory failure?
After chest-tube placement, subcutaneous emphysema expands, oxygenation worsens, and drainage-system movement disappears. This combined problem requires immediate escalation.
What is impaired chest-tube drainage from obstruction or malposition?
A client taking propranolol has active melena, BP 94/58, urine output 15 mL/hr, and lactate 3.8 mmol/L, but the heart rate is 62/min. This interpretation best explains the deceptively normal pulse.
What is beta blockade masking compensation during hemorrhagic shock?
Fever, a new murmur, splinter hemorrhages, and an embolic-appearing lesion raise concern for infective endocarditis. If the client is stable, this diagnostic step should precede antibiotics.
What is obtain multiple blood cultures?
A client with known aortic stenosis now has exertional syncope, angina, dyspnea, and lower blood pressure. This interpretation should drive urgent escalation.
What is symptomatic severe aortic stenosis with reduced cardiac output?