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Question

Difficulty: MediumReduction of Risk Potential

A client experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD) becomes increasingly lethargic. Recent arterial blood gas (ABG) analysis reveals a pH of 7.25, PaCO2 of 72 mm Hg, HCO3 of 28 mEq/L, and PaO2 of 58 mm Hg. To reduce the risk of impending respiratory failure, which intervention should the nurse implement first?

  1. Prepare the equipment for noninvasive positive pressure ventilation or intubation.Answer
  2. B
    Increase the supplemental oxygen to 15 liters per minute via a non-rebreather mask.
  3. C
    Position the client flat in bed to optimize cerebral perfusion and improve arousal.
  4. D
    Prioritize conducting a comprehensive neurological assessment to investigate the lethargy.

Answer

The correct action is to prepare the equipment for noninvasive positive pressure ventilation or intubation.
The client is exhibiting clear signs of acute respiratory failure and CO2 narcosis (lethargy paired with severe respiratory acidosis: pH 7.25 and PaCO2 72 mm Hg). The absolute priority action to reduce the risk of respiratory arrest and death is to assist with ventilation. This actively blows off excess carbon dioxide and improves oxygenation, which is achieved through noninvasive positive pressure ventilation (such as BiPAP) or mechanical intubation.

Step-by-Step Solution

1
Analyze the client's ABG results and neurological status.
The nurse identifies acute respiratory acidosis (pH 7.25, high PaCO2) and CO2 narcosis evidenced by the increasing lethargy.
Recognizing the physiological signs of impending respiratory arrest is the first step in risk reduction.
2
Apply the ABCs (Airway, Breathing, Circulation) framework for prioritization.
The nurse determines that immediate intervention to support breathing and ventilation takes precedence over further assessment or circulation optimization.
Airway and breathing must be secured immediately to prevent cardiopulmonary collapse.
3
Select the intervention that directly addresses the inadequate ventilation.
The nurse prepares for mechanical or positive pressure ventilation.
Ventilatory support is necessary to blow off the excess carbon dioxide and restore a safe blood pH and oxygenation level.

Key Concept

Identifying early indicators of respiratory failure and prioritizing airway and breathing interventions over secondary assessments.
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Topics

Reduction of Risk Potential

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