Examkin

Question

Difficulty: MediumReduction of Risk Potential

A charge nurse is observing a newly licensed nurse care for a 24-year-old client admitted with diabetic ketoacidosis (DKA). The client is lethargic and exhibiting deep, rapid respirations at 32 breaths/minute. Arterial blood gas (ABG) results indicate a pH of 7.23, PaCO2PaCO_2 of 26 mm Hg, and HCO3−HCO_3^- of 14 mEq/L. Which action by the newly licensed nurse requires immediate intervention by the charge nurse?

  1. Coaching the client to breathe into a paper bag to decrease the respiratory rate.Answer
  2. B
    Initiating a rapid intravenous infusion of 0.9%0.9\% sodium chloride as prescribed.
  3. C
    Preparing a continuous intravenous infusion of regular insulin to lower blood glucose.
  4. D
    Withholding prescribed intravenous potassium chloride until the client produces urine.

Answer

Coaching the client to breathe into a paper bag to decrease the respiratory rate.
The newly licensed nurse is attempting to treat the client's rapid breathing as if it were a panic attack (hyperventilation syndrome). However, in diabetic ketoacidosis, deep and rapid breathing (Kussmaul respirations) is a vital compensatory mechanism. The lungs are exhaling large amounts of CO2CO_2 (which acts as an acid in the blood) to help bring the acidic pH back toward normal. Having the client breathe into a paper bag forces them to rebreathe CO2CO_2, defeating the compensatory mechanism and causing the blood pH to drop further, which can lead to cardiovascular collapse and death. The charge nurse must intervene immediately.

Step-by-Step Solution

1
Analyze the client's clinical presentation and Arterial Blood Gas (ABG) results.
The low pH of 7.23 and low HCO3−HCO_3^- of 14 mEq/L indicate metabolic acidosis. The PaCO2PaCO_2 of 26 mm Hg is lower than the normal range, indicating a respiratory compensation effort.
Identifying the primary acid-base imbalance is necessary to determine the physiological state and the appropriateness of clinical interventions.
2
Evaluate the client's respiratory pattern in relation to the ABG values.
The deep, rapid breathing at 32 breaths/minute represents Kussmaul respirations.
The lungs are naturally attempting to compensate for the severe metabolic acidosis by blowing off excess carbon dioxide (an acid) to raise the blood pH.
3
Assess each nursing action to determine if it reduces risk or causes harm.
Using a paper bag would cause the client to rebreathe carbon dioxide, which disrupts the compensatory mechanism and worsens the acidosis. The other actions (administering fluids, insulin, and verifying urine before potassium) are standard, correct interventions for DKA.
The charge nurse must intervene only when a delegated or observed action places the client at significant risk for physiological deterioration.

Key Concept

Compensatory mechanisms in metabolic acidosis (Kussmaul respirations)
Rate this question

Topics

Reduction of Risk Potential

More questions from this topic