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Difficulty: MediumReduction of Risk Potential

A critically ill client is mechanically ventilated via an oral endotracheal tube. The morning arterial blood gas (ABG) analysis reveals a pH of 7.28, PaCO2 of 62 mm Hg, HCO3- of 26 mEq/L, and PaO2 of 70 mm Hg. The client suddenly exhibits profound diaphoresis, restless movements, and begins biting the endotracheal tube. Which intervention should the nurse implement first to mitigate the risk of further physiological deterioration?

  1. Auscultate bilateral lung sounds and prepare to suction the endotracheal tube.Answer
  2. B
    Administer the prescribed intravenous sedative to promote ventilator synchrony.
  3. C
    Increase the fraction of inspired oxygen (FiO2) on the ventilator settings.
  4. D
    Contact the respiratory therapist to change the mechanical ventilation mode.

Answer

The correct action is to auscultate bilateral lung sounds and prepare to suction the endotracheal tube.
The ABG results demonstrate uncompensated respiratory acidosis, indicating inadequate alveolar ventilation. The client's sudden agitation, diaphoresis, and biting of the tube are classic clinical signs of air hunger, often caused by an airway obstruction such as a mucus plug. The priority nursing action is to assess airway patency by auscultating lung sounds and clearing any secretions via suctioning, which directly addresses the root cause of the hypercapnia and reduces the risk of respiratory failure.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) results.
The client has a low pH (7.28) and elevated PaCO2 (62 mm Hg) with a normal HCO3- (26 mEq/L), indicating uncompensated respiratory acidosis.
Identifying the acid-base imbalance is necessary to determine that the client is experiencing inadequate alveolar ventilation (retaining carbon dioxide).
2
Correlate the laboratory values with the physical assessment findings.
The agitation, diaphoresis, and biting of the tube are identified as signs of severe air hunger and potential airway obstruction.
Restlessness is frequently the earliest sign of hypoxia and hypercapnia, meaning the client's behavior is physiological, not purely psychological.
3
Determine the highest priority nursing intervention.
Assessing airway patency (auscultation) and clearing potential blockages (suctioning) is selected as the immediate action.
According to the ABCs (Airway, Breathing, Circulation) of prioritization, clearing a compromised airway is the most critical first step before administering medications or altering equipment.

Key Concept

Interpretation of Arterial Blood Gases and Airway Prioritization
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Topics

Reduction of Risk Potential

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