A nurse is caring for a client diagnosed with Guillain-Barré syndrome who reports increasi… — NCLEX-RN

A nurse is caring for a client diagnosed with Guillain-Barré syndrome who reports increasing difficulty swallowing and generalized weakness. The client is restless, has shallow respirations at 28 breaths/min, and an arterial blood gas (ABG) reveals: $\text{pH} = 7.29$ , $\text{PaCO}_2 = 58 \text{ mm Hg}$ , $\text{HCO}_3^- = 24 \text{ mEq/L}$ , and $\text{PaO}_2 = 62 \text{ mm Hg}$ . Based on these findings, which of the following is the priority nursing action?

A
Apply a non-rebreather mask at 15 L/min to immediately correct the hypoxemia.
Prepare the client for immediate endotracheal intubation and mechanical ventilation.Answer
C
Administer prescribed intravenous sodium bicarbonate to buffer the systemic acidosis.
D
Instruct the client to perform deep-breathing exercises to increase carbon dioxide elimination.

Answer

Prepare the client for immediate endotracheal intubation and mechanical ventilation.

The ABG results demonstrate uncompensated acute respiratory acidosis (

\text{pH} < 7.35

and

\text{PaCO}_2 > 45 \text{ mm Hg}

). In a client with Guillain-Barré syndrome, this hypercapnia, combined with shallow breathing and difficulty swallowing, signifies severe neuromuscular paralysis extending to the diaphragm and bulbar muscles. The client is rapidly losing the physical ability to ventilate. Immediate intubation and mechanical ventilation are required to secure the airway, provide adequate ventilation, and prevent respiratory arrest.

Step-by-Step Solution

Analyze the arterial blood gas (ABG) values.

The results show a

\text{pH}

of 7.29 (acidosis), a

\text{PaCO}_2

of 58 mm Hg (respiratory origin), a normal

\text{HCO}_3^-

, and a

\text{PaO}_2

of 62 mm Hg (hypoxemia).

Accurate interpretation of ABGs is required to identify uncompensated acute respiratory acidosis and hypoxemia.

Correlate the ABG findings with the pathophysiology of Guillain-Barré syndrome.

The syndrome causes ascending neuromuscular paralysis. Shallow breathing, dysphagia, and elevated carbon dioxide indicate that paralysis has severely affected the bulbar and diaphragmatic muscles.

Understanding the disease process explains why the respiratory failure is occurring (pump failure due to muscle weakness).

Determine the most appropriate life-saving intervention.

The client is losing the physical ability to ventilate independently and requires an artificial airway and mechanical ventilation.

Prioritization must focus on ABCs (Airway and Breathing). Since the client cannot physically breathe effectively, mechanical support is the only viable solution.

Key Concept

Management of acute respiratory failure in neuromuscular disorders

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