The nurse is caring for a patient who is in skeletal traction for a femoral fracture and notes that patient assessment data include dyspnea,hypoxia,petechial rash on chest,and hypotension.Which should the nurse implement?

Question

Quizplus · Accepted Answer

These patient data are consistent with clinical indicators for a pulmonary embolism; accordingly the nurse institutes emergency treatment for the patient to restore adequate oxygenation,ventilation,and perfusion and preserve vital organ function.If the patient is stable enough for transport,the healthcare team provides empirical treatment,including supplemental oxygen,fluid resuscitation,and anticoagulation,before performing diagnostic tests to determine the nature of the patient's problem.The patient is not complaining of pain.If chest pain occurs from the pulmonary embolus,the nurse can administer morphine sulfate intravenously to provide pain relief but not at the expense of the respiratory rate or blood pressure.Asking the patient about coughing and repositioning in a semi-Fowler's position are reasonable nursing interventions but are not a priority at this time.The most important nursing intervention is to initiate emergency care related to the symptoms of embolism.

The Nurse Is Caring for a Patient Who Is in Skeletal