Examkin

Question

Difficulty: MediumPhysiological Adaptation

Arterial blood gas (ABG) results for a client with a history of chronic obstructive pulmonary disease (COPD) reveal a pH of 7.28, PaCO2 of 68 mm Hg, HCO3- of 25 mEq/L, and PaO2 of 58 mm Hg. The client is restless and using accessory muscles to breathe. Which initial action by the nurse is the most appropriate?

  1. Assist the client into a high-Fowler's position and coach them on pursed-lip breathing.Answer
  2. B
    Initiate oxygen therapy via a non-rebreather mask at 15 L/min.
  3. C
    Instruct the client to breathe into a paper bag.
  4. D
    Prepare for the administration of intravenous sodium bicarbonate.

Answer

Assist the client into a high-Fowler's position and coach them on pursed-lip breathing.
The client is experiencing acute, uncompensated respiratory acidosis (pH 7.28, PaCO2 68 mm Hg) due to an exacerbation of COPD. The priority is to improve ventilation and facilitate the removal of trapped carbon dioxide. Assisting the client into a high-Fowler's position maximizes chest expansion, while coaching them on pursed-lip breathing creates mild positive airway pressure, keeping airways open longer during exhalation to blow off excess carbon dioxide.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) values to determine the acid-base imbalance.
pH is low (7.28), PaCO2 is high (68 mm Hg), and HCO3- is normal (25 mEq/L).
This indicates acute, uncompensated respiratory acidosis caused by the retention of carbon dioxide.
2
Evaluate the client's clinical presentation alongside the ABG results.
The client is restless, using accessory muscles, and has hypoxemia (PaO2 58 mm Hg) due to COPD exacerbation.
Identifying the root cause (impaired ventilation and air trapping) guides the selection of the most effective nursing intervention.
3
Select the most appropriate initial nursing intervention to address impaired ventilation.
Positioning the client upright and using pursed-lip breathing are the best initial actions.
These non-pharmacologic interventions immediately improve lung expansion, facilitate carbon dioxide exhalation, and decrease the work of breathing without the risks associated with high-flow oxygen in COPD.

Key Concept

Management of acute respiratory acidosis in chronic obstructive pulmonary disease
Rate this question

Topics

Physiological Adaptation

More questions from this topic