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Clinical Nursing Skills

What Should the Nurse Do?

Clinical Nursing SkillsWhat Should the Nurse Do?

What Should the Nurse Do?

An unresponsive patient has been brought to the emergency department, and an ABG is performed. Results indicate a pH of 7.24 and CO2 of 52. The nurse notes the patient’s respiratory rate is 26.
1 .
Based on the definition of hyperventilation, is this patient hyperventilating?
2 .
Why is the patient tachypneic?
3 .
A patient who suffered a MI with significant myocardial tissue damage two weeks ago now has a diagnosis of HF. The nurse notes these recent test and hemodynamics results: T: 98.8°F (37.1°C), HR 122, BP 86/48, RR 16, CO 3.9, CI 1.8. Echocardiogram report includes bilateral ventricles with minimal wall motion and low SV. What results would illustrate signs and symptoms associated with HF?
4 .
A patient presents to the ED with complaint of 10/10 chest pain. The receiving nurse notes the patient is ashen and diaphoretic. Vital signs are as follows: temperature 98.8°F (37.1°C), HR 112, BP 84/56, RR 24, SaO2 94 percent on 2 L O2 by nasal cannula (NC). As the leads are being placed for a twelve-lead ECG, the patient says to the nurse, “Please don’t let me die!” and loses consciousness. The nurse checks for a carotid pulse, but there is none, so the code button is pushed to activate the code team. While awaiting the team’s arrival and the code cart, which action should the nurse take first?

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