Exhibits

A client is admitted to the intensive care unit with multisystem organ dysfunction syndrome (MODS). The client is restless, febrile, and nauseated. Insulin is infusing at 5 units/hour per protocol to keep blood glucose less than 150 mg/dL (8.3 mmol/L). Dopamine is infusing at 5 mcg/kg/minute per protocol to keep mean arterial pressure (MAP) greater than 65 mm Hg. Serum blood glucose is 160 mg/dL and MAP is 66 mm Hg. The client is receiving oxygen at 50% via face mask and has an oxygen saturation of 92%. Which intervention should the nurse implement?

Reference Range:

• Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

A. Apply high-flow oxygen by face mask. The client is in respiratory distress with absent breath sounds over the left lung field, which is highly suggestive of a pneumothorax or hemothorax. High-flow oxygen helps improve oxygenation while preparing for definitive intervention. In cases of tension pneumothorax, oxygen can help reduce hypoxia until a chest tube or needle decompression is performed.
B. Obtain a chest tube insertion kit. Absent breath sounds on one side following chest trauma strongly suggest a pneumothorax or hemothorax, requiring immediate chest tube placement to re-expand the lung and restore normal ventilation. The nurse should ensure that the equipment for thoracostomy (chest tube insertion) is readily available for the healthcare provider.
C. Withhold narcotic pain medication. Pain control is important in trauma patients, as uncontrolled pain can lead to shallow breathing, atelectasis, and respiratory complications. Narcotics should be used cautiously in clients with respiratory distress, but they are not contraindicated if given at appropriate doses with close monitoring.
D. Elevate the head of the bed 45 degrees. Clients with respiratory distress should be positioned with the head of the bed elevated to improve lung expansion. However, in a suspected pneumothorax, the priority is oxygenation and chest tube insertion. If there is hemodynamic instability, the client may require a flat or semi-Fowler’s position instead.
E. Place client in Trendelenburg position. The Trendelenburg position (head down, feet up) is not appropriate in chest trauma patients. This position can increase intra-abdominal pressure, worsen breathing difficulty, and impair lung expansion. It is typically avoided in clients with respiratory distress or suspected pneumothorax.

A. Administer furosemide IV over ten minutes. While slow IV administration is recommended to prevent ototoxicity, the priority concern is that milrinone and furosemide are incompatible when administered in the same IV line. The nurse must first ensure separate IV access before considering the administration rate.
B. Notify the healthcare provider (HCP) of the incompatibility of the two drugs. The nurse does not need to notify the HCP but should instead use a separate IV line or flush the line thoroughly before and after administration if only one access is available. Milrinone and furosemide should never be mixed, as their combination can cause precipitation, leading to catheter occlusion or embolization.
C. Infuse furosemide through a central line to prevent extravasation. Furosemide can be given peripherally or centrally, but the concern here is drug incompatibility, not extravasation. Furosemide is not a vesicant, so central line administration is not required unless no peripheral access is available.
D. Give furosemide through a separate IV access. Milrinone is incompatible with furosemide due to pH differences, which can lead to precipitation and potential catheter occlusion. To ensure safe administration, furosemide should be given through a separate IV line or, if no secondary access is available, the line should be flushed thoroughly before and after administration.