A patient is taking OCP with h/o chronic smoking, now complaining shortness of breath with pain and his ABG report shows pH 7.5, SpO2 60, PCO2 29, HCO3 24. After assessment reveals his vital signs are blood pressure 140/80, pulse rate 110 per minute, respiratory rate 40 per minute. What would be priority nursing intervention?

1. A

   Mechanical ventilation

2. B

   Oxygen administration

3. C

   Soda bicarbonate

4. D

   Monitor for pulmonary embolism

Appeared in: PGIMER Sangrur NO - 2023

Explanation

• The patient's severe hypoxemia, indicated by an SpO₂ of 60%, is a life-threatening condition that requires immediate intervention.
• According to the Airway, Breathing, Circulation (ABC) framework, correcting impaired breathing and oxygenation is the highest priority.
• Administering supplemental oxygen is the fastest and least invasive initial action to increase blood oxygen levels and alleviate respiratory distress.
• The patient's history (OCP use, smoking) and acute symptoms (dyspnea, tachycardia, tachypnea) are classic for a Pulmonary Embolism (PE), where hypoxemia is the primary life threat.

Why Other Options Were Wrong

• Option A: This is a secondary, more invasive intervention. It is not the initial priority action.
• Option C: This medication is used to treat metabolic acidosis. The patient's ABG shows respiratory alkalosis (pH 7.5), so administering sodium bicarbonate would be contraindicated and worsen their condition.
• Option D: This is a passive action. The patient is hemodynamically unstable and requires immediate, life-saving intervention, not just observation.

Related Visual

Clinical Relevance

• Nursing practice connection: Knowing Priority nursing intervention in a patient with suspected pulmonary embolism and acute respiratory distress helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• Recognizing that the combination of oral contraceptive use and smoking creates a very high risk for venous thromboembolism (VTE) and pulmonary embolism (PE) is a critical nursing assessment skill.
• Prioritizing interventions using the ABC framework is a fundamental skill in all emergency situations to address the most life-threatening problems first and prevent patient deterioration.
• What if? If the patient's SpO₂ did not improve with a non-rebreather mask and they became lethargic with a decreasing respiratory rate, the priority would then shift to preparing for intubation and mechanical ventilation, as this would indicate impending respiratory failure.

How to Approach the Question

• First, analyze the patient's history and risk factors. Note that OCP use and chronic smoking are major red flags for Pulmonary Embolism (PE).
• Next, interpret the clinical data. The vital signs (tachycardia, tachypnea) and ABG results (severe hypoxemia, respiratory alkalosis) are classic signs of PE.
• Identify the most life-threatening problem from the data. The SpO₂ of 60% represents severe hypoxemia, which is an immediate threat to life.
• Apply the ABC (Airway, Breathing, Circulation) principle to prioritize care. The 'Breathing' component is critically compromised due to hypoxemia.
• Evaluate the options based on the ABC priority. Oxygen administration directly addresses the 'Breathing' problem. The other options are either secondary (ventilation), contraindicated (bicarbonate), or too passive (monitoring) for this acute situation.

Concept Tested & Keywords

• Concept Tested: Priority nursing intervention in a patient with suspected pulmonary embolism and acute respiratory distress.
• Stem keywords: OCP, chronic smoking, shortness of breath, ABG, pH 7.5, SpO2 60, PCO2 29, pulse rate 110
• Lead-in keywords: priority nursing intervention
• Clinical cues: OCP + smoking: High risk for venous thromboembolism (VTE) and Pulmonary Embolism (PE).
• Clinical cues: SpO2 60%: Indicates severe, life-threatening hypoxemia requiring immediate action.

Question ID

QA0XdkcUpRsZF1WFCLFXAL

Copy ID

Reference Book

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 p. 664-666

E6 Medicine Harrison 22e Part 2 p. 163-165