A critical care nurse is managing a client diagnosed with acute respiratory failure who is receiving mechanical ventilation. The laboratory reports the following arterial blood gas results: pH 7.28, PaCO2 62 mm Hg, PaO2 55 mm Hg, and HCO3 24 mEq/L. To reduce the risk of further physiological deterioration, which of the following interventions are appropriate? Select all that apply.
- Auscultate breath sounds and assess oxygen saturation prior to initiating endotracheal suctioningAnswer
- Maintain the client's upper body in a semi-Fowler's alignment to prevent ventilator-associated complicationsAnswer
- CAdminister prescribed intravenous sodium bicarbonate to correct the identified uncompensated metabolic acidosis
- DReposition the client into a flat, dorsal recumbent alignment to maximize pulmonary blood flow
- EPalpate the abdominal quadrants for distention before auscultating for bowel sounds during the physical assessment
- FContinue the client's scheduled daily hygiene care before responding to a sustained high-pressure ventilator alarm
Answer
The appropriate interventions are to auscultate breath sounds prior to endotracheal suctioning and to maintain the client's upper body in a semi-Fowler's alignment.
The correct actions focus on evidence-based risk reduction strategies for mechanically ventilated clients. Assessing lung sounds before suctioning prevents unnecessary trauma and hypoxia, while maintaining an elevated upper body reduces the risk of aspiration and ventilator-associated pneumonia. These actions directly mitigate physiological risks.
Step-by-Step Solution
Key Concept
Prioritization and risk reduction in mechanically ventilated clients, including accurate ABG interpretation and implementation of ventilator safety bundles.
Estimated Time:2m 0s