A nurse is caring for a client admitted with a severe acute asthma exacerbation. The client has been receiving continuous albuterol nebulization and intravenous corticosteroids. During reassessment, the nurse observes that the client is becoming increasingly lethargic and the respiratory rate has decreased from 34 to 12 breaths per minute. Auscultation reveals a 'silent chest' with no audible wheezing. The latest arterial blood gas (ABG) results on room air are: pH 7.28, PaCO2 62 mm Hg, PaO2 55 mm Hg, and HCO3 26 mEq/L. Which action is the priority for the nurse to reduce the risk of a fatal outcome?
- Activate the rapid response team and prepare the client for immediate endotracheal intubation.Answer
- BAdminister an intravenous infusion of sodium bicarbonate to rapidly neutralize the uncompensated respiratory acidosis.
- CPlace the client in a high-Fowler's position and firmly encourage them to perform deep pursed-lip breathing.
- DRecognize the cessation of wheezing as a sign of bronchospasm resolution and prioritize assessing other assigned clients.
Answer
The priority action is to activate the rapid response team and prepare the client for immediate endotracheal intubation.
The correct answer addresses the immediate need for airway management. The client is exhibiting classic signs of impending respiratory failure: decreasing level of consciousness (lethargy), a paradoxical drop in respiratory rate due to muscle fatigue, and a 'silent chest'. A silent chest indicates severe airflow obstruction where there is not enough air movement to produce a wheeze. The ABG results confirm acute uncompensated respiratory acidosis with severe hypoxemia. The absolute priority is securing the airway and initiating mechanical ventilation to prevent cardiac and respiratory arrest.
Step-by-Step Solution
Key Concept
Recognizing impending respiratory failure in asthma and prioritizing airway management.