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학습 자료 둘러보기 →A pulmonary embolism (PE) causes a ventilation-perfusion (V/Q) mismatch, where blood flow to oxygenated alveoli is obstructed. The immediate physiological threat is severe hypoxemia, which can rapidly lead to decompensation and cardiac arrest.
The first nursing action must be to position the client in high Fowler's position and administer oxygen. This directly targets the ABCs (Airway, Breathing, Circulation) by maximizing lung expansion and increasing the concentration of available oxygen to improve diffusion into the bloodstream.
Do not delay oxygen therapy to obtain diagnostic tests like a CT pulmonary angiogram or to administer anticoagulants. Stabilizing respiratory status is the most time-sensitive intervention to prevent deterioration. Monitor for signs of respiratory failure and be prepared to escalate care.
학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.