An intensive care nurse evaluates a critically ill client being treated for severe viral pneumonia. Over the past 30 minutes, the client has become increasingly agitated and disoriented. Current vital signs reveal a heart rate of 126 beats/min, a respiratory rate of 34 breaths/min, and a blood pressure of 98/78 mm Hg. Stat arterial blood gas (ABG) analysis on a non-rebreather mask demonstrates a pH of 7.26, of 64 mm Hg, of 52 mm Hg, and of 24 mEq/L. What is the most appropriate action by the nurse to mitigate the risk of immediate cardiorespiratory arrest?
- Assemble the necessary equipment for immediate rapid sequence intubation and mechanical ventilation.Answer
- BAdminister a continuous intravenous infusion of sodium bicarbonate to resolve the client's metabolic acidosis.
- CAdminister a prescribed intravenous sedative to manage the agitation and decrease the client's myocardial oxygen demand.
- DLower the head of the bed to a flat, supine position to promote venous return and increase cerebral perfusion.
Answer
The nurse must assemble the necessary equipment for immediate rapid sequence intubation and mechanical ventilation.
The correct action is to prepare for immediate intubation and mechanical ventilation. The client's profound hypoxemia ( of 52 mm Hg despite high-flow oxygen via a non-rebreather mask), severe uncompensated respiratory acidosis (pH 7.26, 64 mm Hg), and signs of impending shock (narrowing pulse pressure of 20 mm Hg, agitation, tachycardia) indicate acute respiratory failure. Securing the airway and providing mechanical ventilation is the most critical intervention to mitigate the risk of imminent cardiorespiratory arrest.
Step-by-Step Solution
Key Concept
Prioritizing airway management in clients with uncompensated respiratory acidosis and impending shock