The nurse is caring for a client. Which of the following actions should the nurse take? Select all that apply.
Explanation & Rationale
A. Prepare for chest tube placement: Chest tube placement is indicated for conditions like pneumothorax or pleural effusion, which are not clearly present in this scenario. Immediate interventions should focus on stabilizing the client and evaluating cardiopulmonary status first. B. Ensure that the client has venous access: Establishing IV access is essential for rapid administration of medications, fluids, or emergency interventions if the client’s condition deteriorates. This is a priority in acute postoperative complications. C. Place the client in High Fowler's position: Elevating the head of the bed improves lung expansion, reduces dyspnea, and enhances oxygenation in a client experiencing sudden respiratory distress and crackles, which may indicate pulmonary edema or fluid overload. D. Activate the rapid response team: The client exhibits acute respiratory distress, hypoxemia, tachypnea, and cardiovascular changes. Activating the rapid response team ensures timely advanced intervention and evaluation to prevent further deterioration. E. Administer fondaparinux as prescribed: Postoperative clients following total hip arthroplasty are at high risk for venous thromboembolism. Administering anticoagulant therapy, such as fondaparinux, helps prevent pulmonary embolism, which could be causing the client’s sudden dyspnea. F. Administer midazolam as prescribed: Midazolam is a sedative and would not address the client’s acute respiratory distress. Sedation could worsen hypoxemia and respiratory compromise in this scenario.