1430: 72-year-old male was brought to the ED with reports of dyspnea, chest pain, diaphoresis, and restlessness. The client's daughter reports that he recently took a long drive across several states and that the symptoms started abruptly. The client's oxygen saturation was 80% on room air and improved to 86% on 100% FiO2 via a nonrebreather mask. The physician was immediately notified at this time of the client's condition and came to the bedside for evaluation.
1442: The physician ordered rapid sequence intubation medications for immediate endotracheal intubation (ETT). The physician intubated the client using a #8 ETT and connected the client to mechanical ventilation using assist-control at a tidal volume of 500 mL, rate of 12/minute, 100% FiO2, PEEP 5 cm H2O. Post-intubation vital signs: T 99° F (37° C), P110, RR 12, BP 90/62, pulse oximetry reading 98%.
The nurse has reviewed both of the Nurses’ Note entries and is planning care for the client
➢ For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client
- A. Request an order for a chest radiograph (x-ray)
- B. Obtain an order for an arterial blood gas (ABG)
- C. Collaborate with respiratory therapy to assist in the client's care
- D. Place the client in low-Fowler's position
- E. Request an order to administer an 0.45% saline intravenous fluid bolus.
- F. Turn the client every four hours
- G. Suction the endotracheal tube (ETT) every two hours
- H. Prepare for end-tidal carbon dioxide [ETCO2] monitoring
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