Question

A client presents to the emergency room complaining of dyspnea, shortness of breath, and a productive cough. The vital signs are temperature \(101.4^{\circ} \mathrm{F}\), respiratory rate 30 , heart rate 108 , and \(\mathrm{BP} 124 / 80\). The client is receiving oxygen, with an oxygen saturation rate of \(86 \%\). Which of the following physician's orders should the nurse complete first? A. Obtain a chest \(x-r a y\) B. Administer acetaminophen (Tylenol) \(\mathrm{X}\) grain C. Obtain arterial blood gases D. Administer chlorpheniramine/hydrocodone (Tussionex)

Short answer

Answer: The nurse should first complete the order to obtain arterial blood gases.

Step-by-step solution

Review the information

Firstly, review the given information: the client's symptoms, vital signs, and oxygen saturation rate. Here are the main points: - Symptoms: dyspnea, shortness of breath, and a productive cough - Vital signs: temperature \(101.4^{\circ}\mathrm{F}\), respiratory rate \(30\), heart rate \(108\), and \(\mathrm{BP} 124/80\) - Oxygen saturation rate: \(86\%\)

Examine the physician's orders

Next, examine the four physician's orders to determine which should be completed first: A. Obtain a chest \(x-r a y\) B. Administer acetaminophen (Tylenol) \(\mathrm{X}\) grain C. Obtain arterial blood gases D. Administer chlorpheniramine/hydrocodone (Tussionex)

Determine the priority

Now we need to determine which order is the most critical for treating the patient: - A chest \(x - r a y\) will provide diagnostic information, but it won't provide immediate relief to the client. - Administering acetaminophen (Tylenol) would help reduce the client's fever, but it will not address their breathing issues. - Obtaining arterial blood gases is essential to assess the client's oxygenation status, which is a critical finding in this situation. - Administering chlorpheniramine/hydrocodone (Tussionex) may help suppress the cough, but it does not address the low oxygen saturation rate directly.

Choose the first order to complete

Since the client's low oxygen saturation rate is the most urgent issue to address, we can determine that the first order the nurse should complete is: C. Obtain arterial blood gases This will give a better understanding of the client's oxygenation status and is the most crucial step in treating the patient's condition at this stage.

Key concepts

Nursing Assessment

Nursing assessment is a foundational step in patient care. It involves collecting and analyzing information about a patient's health status to guide the care process. In this scenario, the nurse observes key symptoms: dyspnea (difficulty breathing), shortness of breath, and a productive cough. These signs are crucial as they can indicate respiratory distress, possibly caused by infection or other underlying conditions.
Vital signs such as an elevated temperature of 101.4°F, a high respiratory rate of 30 breaths per minute, and a heart rate of 108 beats per minute provide further clues to the patient's condition. These indicators suggest a possible infection and stress on the respiratory and cardiovascular systems. Additionally, the oxygen saturation rate of 86% is alarmingly low, which signifies insufficient oxygen in the blood.

Key points to note:

• Continual monitoring of the patient's condition, especially changes in vital signs.
• Understanding that thorough assessment enables a targeted and effective intervention plan.
• Identifying symptoms and correlating them with potential underlying issues.

Emergency Nursing Care

Emergency nursing care requires swift and effective action to stabilize and treat patients in critical situations. When dealing with someone who has a low oxygen saturation rate like 86%, the primary goal is to ensure adequate oxygenation immediately.

The nurse must prioritize interventions that directly impact the patient's ability to breathe. This involves carefully following physician’s orders but also using professional judgment to sequence actions based on urgency. For instance, obtaining arterial blood gases is prioritized since it will provide crucial information about the patient's respiratory efficiency and guide further treatment decisions.

Helpful strategies include:

• Using oxygen therapy effectively to maintain optimal oxygen saturation levels.
• Monitoring the patient closely for any signs of deterioration.
• Communicating promptly with healthcare providers for timely interventions.

Patient Management

Patient management in the healthcare setting involves coordinating appropriate interventions to address the patient’s immediate and long-term needs. In acute cases like the one presented, the nurse's role includes both understanding the severity of the condition and implementing the correct order of procedures.

In managing such a patient, problem-solving skills are crucial. The nurse must determine which physician's order takes precedence. While a fever indicates infection and pain relief, managing the low oxygen saturation is more critical in this context.

The following are essential components of effective patient management:

• Prioritizing procedures that address life-threatening conditions first.
• Ensuring coordinated care delivery among all caregivers.
• Evaluating the effectiveness of interventions and making necessary adjustments.

Oxygenation Assessment

Oxygenation assessment is one of the critical evaluations in patients presenting with respiratory issues. An accurate assessment provides the healthcare team with indispensable data to manage the patient's oxygenation status.

To perform an oxygenation assessment, the nurse evaluates the oxygen saturation level. In this case, an oxygen saturation of 86% warrants immediate attention, as it indicates hypoxemia, where there is a deficiency of oxygen in the bloodstream.

Obtaining arterial blood gases is prioritized for accurate measurement of oxygen and carbon dioxide levels in the blood. This assessment will help determine the severity of the patient’s respiratory compromise and guide the next steps in treatment.
Key considerations include:

• Ensuring prompt intervention when oxygen saturation is below normal levels.
• Understanding the implications of hypoxemia on overall health.
• Utilizing data from the oxygenation assessment to adjust oxygen delivery and other treatments accordingly.