A client receiving mechanical ventilation for severe acute respiratory distress syndrome (… — NCLEX-RN

A client receiving mechanical ventilation for severe acute respiratory distress syndrome (ARDS) has the following ventilator settings and clinical data:

- Ventilator settings: Assist-control (AC) mode, $\text{FiO}_2$ $0.80$ , respiratory rate $18 \text{ breaths/min}$ , tidal volume $400 \text{ mL}$ , positive end-expiratory pressure (PEEP) $15 \text{ cm H}_2\text{O}$ .
- Arterial blood gas (ABG) results: pH $7.27$ , $\text{PaCO}_2$ $59 \text{ mm Hg}$ , $\text{PaO}_2$ $54 \text{ mm Hg}$ , $\text{HCO}_3^-$ $26 \text{ mEq/L}$ .
- Vital signs: Blood pressure $82/50 \text{ mm Hg}$ , heart rate $128 \text{ beats/min}$ .
- Hemodynamic data: Central venous pressure (CVP) $15 \text{ mm Hg}$ .
- Physical assessment: Distant breath sounds on the right anterior chest and tracheal deviation to the left.

Which of the following interventions should the nurse anticipate implementing immediately? Select all that apply.

Prepare for an immediate right-sided needle thoracostomyAnswer
Anticipate a prescription to decrease the positive end-expiratory pressure (PEEP)Answer
Gather sterile supplies for a right-sided chest tube insertionAnswer
D
Administer a rapid intravenous bolus of $0.9\%$ sodium chloride
E
Increase the mechanical ventilator's tidal volume to resolve the hypercapnia
F
Prepare for a stat portable chest radiograph to confirm the diagnosis prior to intervention

Answer

The correct interventions are preparing for an immediate right-sided needle thoracostomy, anticipating a prescription to decrease the PEEP, and gathering supplies for a right-sided chest tube insertion.

The client is experiencing a right-sided tension pneumothorax, a life-threatening complication of barotrauma caused by the high PEEP setting (15 cm H2O). The trapped air in the right pleural space collapses the lung (distant breath sounds) and shifts the mediastinum to the left (tracheal deviation). This massive pressure compresses the vena cava, dropping venous return and causing obstructive shock (hypotension, tachycardia) while causing blood to back up (elevated CVP). The nurse must immediately prepare for a right-sided needle thoracostomy to release the pressure, followed by a chest tube for definitive management. Additionally, the PEEP should be decreased to limit further air leaking into the pleural space.

Step-by-Step Solution

Analyze the physical assessment findings.

The client has distant right-sided breath sounds and tracheal deviation to the left.

These are classic hallmark signs of a right-sided tension pneumothorax, where trapped air pushes mediastinal structures away from the affected side.

Evaluate the ventilator settings as a potential cause.

The client is receiving a very high PEEP of 15 cm H2O.

High PEEP significantly increases intrathoracic pressure and the risk of alveolar rupture (barotrauma), leading directly to a pneumothorax.

Correlate the hemodynamic and vital sign data with the pathology.

The client has hypotension (82/50 mm Hg), tachycardia (128 beats/min), and an elevated CVP (15 mm Hg).

The extreme intrathoracic pressure from the tension pneumothorax compresses the vena cava, severely decreasing venous return. This causes obstructive shock (hypotension/tachycardia) and venous blood backing up (elevated CVP).

Determine the priority emergency interventions.

Select actions that immediately relieve the intrathoracic pressure and prevent further air accumulation.

Needle decompression provides immediate relief, a chest tube provides definitive drainage, and reducing PEEP prevents further air from being forced into the pleural space.

Key Concept

Tension Pneumothorax and Obstructive Shock in Mechanical Ventilation

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