The nurse is assessing a client with a history of deep vein thrombosis (DVT) who is admitted for possible pulmonary embolism (PE). It is important to report which finding to the healthcare provider immediately?

A. Compensated respiratory acidosis with hypoxia: The pH is at the low end of normal (7.35), PaCO₂ is elevated (60 mm Hg), and HCO₃⁻ is also elevated (35 mEq/L), indicating the kidneys are compensating for chronic respiratory acidosis. The PaO₂ is low (60 mm Hg), confirming hypoxia.

B. Compensated respiratory alkalosis with normal oxygenation: Respiratory alkalosis would be indicated by a high pH and low PaCO₂, which are not present here. Also, the client is hypoxic, not normally oxygenated, as shown by the PaO₂ of 60 mm Hg.

C. Acute respiratory acidosis: In acute respiratory acidosis, the PaCO₂ would be high with a low pH and little to no elevation in HCO₃⁻. The elevated HCO₃⁻ here shows that compensation has occurred, indicating the condition is not acute.

D. Normal acid-base balance: Although the pH falls within normal limits, the PaCO₂ and HCO₃⁻ are significantly abnormal. The body has compensated for the respiratory acidosis, but the acid-base balance is not normal due to the underlying pathology and associated hypoxia.

• Pulmonary embolism (PE): The client presents with sudden-onset chest pain, dyspnea, hypoxia (SpO₂ 89% on room air), tachypnea, tachycardia, and cyanosis. These are classic signs of a pulmonary embolism, especially following trauma or immobility, such as after a lower extremity fracture and recent surgery.
• Start continuous cardiorespiratory monitoring: Given the client's compromised respiratory status and cardiac involvement, continuous monitoring is needed to detect worsening hypoxia, dysrhythmias, or hemodynamic instability associated with PE.
• Administer heparin subcutaneous: Anticoagulation with heparin is the standard first-line treatment for PE. It prevents further clot formation and reduces the risk of clot propagation, helping stabilize the client while further evaluation continues.
• Oxygen saturation: Monitoring SpO₂ helps assess the client's respiratory function and the effectiveness of oxygen therapy or anticoagulation. PE impairs gas exchange, so O₂ saturation is a key indicator of clinical progress.
• Cardiac markers: PE can strain the right side of the heart, leading to ischemia. Monitoring cardiac markers helps detect myocardial stress or injury secondary to increased pulmonary vascular resistance.
• Deep vein thrombosis (DVT): While DVT is a risk factor, the client’s acute chest symptoms and hypoxia suggest the clot has embolized to the lungs, indicating PE rather than isolated DVT.
• Myocardial infarct: Although chest pain and increased cardiac workload are seen in both MI and PE, the absence of cardiac history, coupled with low oxygen saturation and recent surgery, makes PE more likely than MI.
• Adult respiratory distress syndrome (ARDS): ARDS involves diffuse alveolar damage and is usually a complication of sepsis or trauma. This client’s symptoms developed suddenly and asymmetrically, favoring PE over ARDS.
• Prepare client for mechanical ventilation: Mechanical ventilation may be needed if the client deteriorates, but his current oxygen saturation and respiratory rate do not yet require intubation.
• Get consent signed for angioplasty: Angioplasty is used for coronary artery occlusion (e.g., in MI), not PE. The client's presentation is not consistent with myocardial infarction requiring catheter intervention.
• Arrange for surgeon to establish artificial airway via tracheostomy: A tracheostomy is not an emergency intervention for acute hypoxia due to PE. Airway is currently patent and oxygenation, while impaired, is being monitored non-invasively.
• Kidney function: While important for general monitoring, it is not the most relevant parameter in assessing PE progression unless complications arise from anticoagulation therapy.
• Presence of petechiae of the thorax: Petechiae is a sign more specific to fat embolism syndrome, particularly after long bone fractures. The client has a lower leg fracture with chest pain but no evidence of petechiae.
• Ventilator settings: The client is not mechanically ventilated, so ventilator settings are not relevant at this point. Monitoring focuses on spontaneous respiratory function and perfusion.