A client who was extubated 2 hours ago is becoming increasingly restless. The last vital signs before extubation were pulse 88 beats/min, respirations 18 breaths/min, blood pressure (138/78)mm Hg, and PaCO₂ 45 mm Hg. Current vital signs include pulse 104 beats/min, respirations 26 breaths/min, blood pressure (140/80) mm Hg, and PaCO₂ 62 mm Hg. The nurse would A) administer a nebulized bronchodilator. B) assist with reintubation. C) obtain a complete blood count (CBC). D) prepare the client for a tracheostomy.

Question

Quizplus · Accepted Answer

The nurse should assess the client for indications of respiratory distress and hypoxemia, as evidenced by restlessness, irritability, tachycardia, tachypnea, and decreased PaO₂ or increased PaCO₂. If these manifestations are noted, the nurse should notify the physician and prepare for reintubation.

A Client Who Was Extubated 2 Hours Ago Is Becoming