hard · NCLEX-RN physiological
Nurses' Notes: 1400: Client 2 days post-op hip replacement. Suddenly reports sharp chest pain and shortness of breath. Vital Signs: HR 118, RR 28, SpO2 86% on room air. Client appears anxious and diaphoretic.
The nurse suspects an acute pulmonary embolism. Place the following nursing actions in the correct sequence of priority.
- Elevate the head of the bed to high-Fowler's position.
- Apply oxygen via non-rebreather mask at 10-15 L/min.
- Obtain a full set of vital signs and pulse oximetry.
- Notify the healthcare provider and the Rapid Response Team.
- Initiate large-bore IV access for fluid and medication administration.
- Prepare to administer IV Heparin as prescribed.
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