A Patient Is Admitted to the Cardiac Surgical Intensive Care

A patient is admitted to the cardiac surgical intensive care unit after cardiac surgery.Four hours after admission to the surgical intensive care unit at 4 PM,the patient has stable vital signs and normal arterial blood gases (ABGs) ,and is placed on a T-piece for ventilatory weaning.The following information pertains to the 1900 assessment.
$\begin{array}{|l|l|}\hline {\text { Assessments and Vital Signs }} & {\text { Nursing Action }} \\\hline \text { Restless } & \text { Performs complete assessment } \\\hline \text { Increased to } 110 \text { beats/min } & \text { Suctions patient for pink, frothy secretions } \\\hline \text { Respirations } 36 \text { breaths/min } & \begin{array}{l}\text { Obtains prescriptions from provider for } \\\text { ABGs, electrolyte levels, and portable } \\\text { chest x-ray }\end{array} \\\hline \text { Blood pressure } 156 / 98 \mathrm{~mm} \mathrm{Hg} & \\\hline \text { Sinus tachycardia } & \\\hline 10 \mathrm{PVCs} / \mathrm{min} & \\\hline \text { Elevated pulmonary artery pressure } & \\\hline \text { Loud crackles throughout } & \\\hline \begin{array}{l}\text { New } \mathrm{ABGs}: \\\text { pH: } 7.28\end{array} & \\\mathrm{PaCO}_{2}: 46 \mathrm{~mm} \mathrm{Hg} \\\mathrm{Bicarbonate:} 22 \mathrm{mE} / \mathrm{L} & \\\mathrm{PaO}_{2}: 58 \mathrm{~mm} \mathrm{Hg} \\\mathrm{O}_{2} \text { saturation: } 88 \%\\\hline\end{array}$
What action by the nurse is best?

A) Prepare for rapid intubation.
B) Increase the patient's oxygen.
C) Prepare to administer a diuretic.
D) Change the ventilator settings.

Correct Answer:

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