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Difficulty: MediumPhysiological Adaptation

An older adult client is brought to the emergency department after awaking with severe orthopnea and a frothy, pink-tinged cough. The client appears extremely agitated and has a respiratory rate of 34 breaths/minute. Arterial blood gas (ABG) values on room air are pH 7.26, PaCO2 62 mm Hg, PaO2 52 mm Hg, and HCO3 24 mEq/L. Which of the following actions should the nurse implement? (Select all that apply.)

  1. Position the client upright with the legs dangling over the edge of the bed.Answer
  2. Prepare the client for immediate noninvasive positive pressure ventilation (NIPPV).Answer
  3. Administer prescribed intravenous loop diuretics.Answer
  4. D
    Administer intravenous sodium bicarbonate to correct the uncompensated acidosis.
  5. E
    Initiate a rapid intravenous infusion of 0.9% sodium chloride to support systemic perfusion.
  6. F
    Instruct the unlicensed assistive personnel (UAP) to perform a focused lung auscultation while gathering medications.

Answer

The correct actions include positioning the client upright with legs dangling, preparing for noninvasive positive pressure ventilation, and administering intravenous loop diuretics.
The client's presentation of a frothy, pink-tinged cough and extreme orthopnea indicates acute pulmonary edema, a life-threatening complication of heart failure. The ABG results demonstrate uncompensated respiratory acidosis with severe hypoxemia. Priority nursing actions focus on reducing venous return (preload) by positioning the client upright with legs dangling, reducing fluid volume with loop diuretics, and improving gas exchange using noninvasive positive pressure ventilation to force fluid out of the alveoli and clear retained carbon dioxide.

Step-by-Step Solution

1
Analyze the clinical presentation (orthopnea, frothy pink-tinged cough, agitation, tachypnea).
The findings strongly indicate acute pulmonary edema, a life-threatening complication of heart failure characterized by fluid in the alveoli.
Identifying the underlying pathophysiology is required to select interventions that reduce fluid volume rather than increase it.
2
Interpret the arterial blood gas (ABG) values: pH 7.26 (acidotic), PaCO2 62 mm Hg (elevated/acidotic), PaO2 52 mm Hg (hypoxemic), HCO3 24 mEq/L (normal).
The ABG indicates uncompensated respiratory acidosis with severe hypoxemia.
Understanding the acid-base imbalance guides respiratory interventions and prevents inappropriate administration of metabolic buffers.
3
Select interventions that safely address both the fluid overload and the acute respiratory failure.
Appropriate actions include dependent positioning to reduce preload, NIPPV to improve gas exchange and clear CO2, and loop diuretics to remove excess fluid. Inappropriate actions include administering fluids, giving bicarbonate, or improperly delegating assessments.
Nursing care must rapidly reverse the physiological decompensation while adhering to the RN scope of practice.

Key Concept

Management of Acute Pulmonary Edema and Respiratory Acidosis
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Topics

Physiological Adaptation

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