Examkin

Question

Difficulty: MediumPhysiological Adaptation

A nurse evaluates a client admitted with community-acquired pneumonia and a comorbidity of heart failure. The client is receiving continuous oxygen therapy at 3 L/min3\text{ L/min} via nasal cannula. Over the past hour, the client has become increasingly restless with a respiratory rate of 32 breaths/min32\text{ breaths/min}. Arterial blood gas analysis reveals a pH value of 7.527.52, a PaCO2PaCO_2 of 28 mm Hg28\text{ mm Hg}, a PaO2PaO_2 of 58 mm Hg58\text{ mm Hg}, and a bicarbonate level of 24 mEq/L24\text{ mEq/L}. Which action should the nurse take first?

  1. A
    Instruct the client to breathe slowly into a paper bag.
  2. B
    Place the client in a supine position to optimize systemic perfusion.
  3. Apply a non-rebreather mask and notify the rapid response team.Answer
  4. D
    Administer the prescribed as-needed intravenous lorazepam.

Answer

The highest priority action is to apply a non-rebreather mask and immediately alert the rapid response team to aggressively manage the refractory hypoxemia.
The client's laboratory parameters indicate severe hypoxemia (PaO2PaO_2 less than 60 mm Hg60\text{ mm Hg}). The extreme tachypnea (causing uncompensated respiratory alkalosis) and restlessness are direct physiological adaptations attempting to correct the oxygen deficit. The most critical intervention is to treat the root cause by providing high-concentration oxygen via a non-rebreather mask and immediately activating the rapid response team to prevent impending respiratory failure.

Step-by-Step Solution

1
Analyze the assessment data and arterial blood gas results.
The findings reveal severe hypoxemia (PaO2PaO_2 of 58 mm Hg58\text{ mm Hg}) occurring despite supplemental oxygen therapy.
Identifying the primary physiological disturbance is the first step in clinical judgment.
2
Interpret the client's presenting symptoms and acid-base imbalance in context.
The tachypnea, resulting respiratory alkalosis, and restlessness are direct physiological compensatory responses to profound tissue hypoxia.
Distinguishing between a primary disease process and a secondary compensatory mechanism ensures interventions target the root cause rather than the symptoms.
3
Determine the most critical priority based on the ABCs (Airway, Breathing, Circulation).
The underlying cause of the deterioration is a failure in oxygenation, dictating that immediate escalation of oxygen delivery and emergency medical support are paramount.
Failing to correct profound hypoxemia will rapidly lead to respiratory failure and cardiac arrest.

Key Concept

Physiological Adaptation to Hypoxemia and Prioritization
Estimated Time:1m 30s
Rate this question

Topics

Physiological Adaptation

More questions from this topic