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Difficulty: HardReduction of Risk Potential

A client is receiving care 4 hours after a right-sided pneumonectomy. The nurse notes the client has become increasingly restless. Current vital signs include a blood pressure of 138/86 mm Hg, heart rate of 118/min, and respiratory rate of 28/min. Arterial blood gas (ABG) analysis reveals a pH of 7.28, PaCO2 of 56 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 64 mm Hg. Which intervention should the nurse implement immediately to reduce the risk of further physiological deterioration?

  1. Place the client in a right lateral position and ensure the head of the bed is elevatedAnswer
  2. B
    Reposition the client onto their left side to maximize perfusion and ventilation to the remaining lung
  3. C
    Administer intravenous sodium bicarbonate to buffer the metabolic component of the acid-base imbalance
  4. D
    Auscultate the right hemithorax for adventitious breath sounds prior to applying supplemental oxygen

Answer

Place the client in a right lateral position and ensure the head of the bed is elevated.
Following a pneumonectomy (complete removal of a lung), the standard of care to reduce the risk of respiratory compromise is to position the client on their operative side (in this scenario, the right side) or flat on their back. This critical positioning strategy ensures that the remaining functioning lung (the left lung) is positioned uppermost. This prevents the weight of the heart and mediastinal structures from compressing the healthy lung, thereby maximizing its ability to expand and participate in gas exchange. Elevating the head of the bed further facilitates diaphragmatic excursion to help resolve the client's acute respiratory acidosis and hypoxemia.

Step-by-Step Solution

1
Interpret the client's vital signs and Arterial Blood Gas (ABG) results.
The ABGs show a low pH (7.28), elevated PaCO2 (56), normal HCO3 (24), and low PaO2 (64). This indicates uncompensated respiratory acidosis with hypoxemia.
Accurate ABG interpretation is required to identify the precise physiological decompensation occurring (respiratory failure).
2
Analyze the specific surgical procedure (right-sided pneumonectomy) and its implications for risk reduction.
A pneumonectomy involves the removal of an entire lung. The right lung is absent, meaning the client is entirely dependent on the left lung for gas exchange.
Surgical context dictates which nursing interventions are safe or strictly contraindicated to prevent life-threatening complications.
3
Determine the priority intervention to optimize gas exchange and reduce risk.
The client must be positioned on their operative side (right side) or supine, with the head of the bed elevated.
Placing the client on the operative side ensures the fluid-filled empty space remains dependent, allowing the remaining 'good' lung (left lung) to remain uppermost. This maximizes its expansion and improves ventilation to correct the respiratory acidosis.

Key Concept

Post-Pneumonectomy Positioning and ABG Analysis
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Topics

Reduction of Risk Potential

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