Question:

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician prescriptions include the following: oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/min. The nurse should first: 

1. Increase the oxygen flow rate from 2 to 4 L/min. 

2. Call the physician immediately. 

3. Provide reassurance to the client. 

4. Obtain a sample for arterial blood gas analysis.

The first action is to increase the oxygen flow rate from 2 to 4 L/min to help ensure adequate oxygenation for the client. Although it is important to notify the physician for additional prescriptions and to obtain further assessment data, such as arterial blood gas measurements, it is a priority to support the client’s cardiopulmonary system. It would be appropriate to reassure the client while these other interventions are occurring. 

CN: Reduction of risk potential; CL: Synthesize

Answer:1

翻译

问题：

一位病人因疑似肺栓塞而入院。医生的处方包括：每根鼻插管2到4升/分钟氧气，始终进行血氧测定，并以100毫升/小时的速度静脉注射5%葡萄糖。病人呼吸困难加剧，呼吸频率为32次/分钟。护士应首先：

1.将氧气流速从2升/分钟增加到4升/分钟。

2.马上打电话给医生。

3.向病人提供保证。

4.获取动脉血气分析样本。

答案：1

第一个措施是将氧气流速从2升/分钟增加到4升/分钟，以确保为病人提供充足的氧气。尽管通知医生额外的处方和获得进一步的评估数据（如动脉血气测量）很重要，但优先考虑的是支持病人的心肺系统。在进行其他干预时，向病人保证是恰当的。

CN:降低风险可能性；CL:综合

小编寄语：Troubles in the world, half from survival, half from care.世间的烦恼，一半源于生存，一半源于计较。