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Difficulty: MediumReduction of Risk Potential

A nurse is caring for a client who is two hours postoperative following a right-sided pneumonectomy. The client is drowsy but arousable. The latest arterial blood gas (ABG) results show a pH of 7.31, PaCO2 of 52 mm Hg, PaO2 of 72 mm Hg, and HCO3- of 25 mEq/L. Which of the following actions should the nurse take to reduce the client's risk of further physiological deterioration?

  1. A
    Turn the client strictly onto the non-operative left side to prevent physical pressure on the bronchial stump.
  2. B
    Prepare to administer a prescribed intravenous dose of sodium bicarbonate to correct the metabolic acidosis.
  3. C
    Instruct the unlicensed assistive personnel to adjust the supplemental oxygen flow rate and closely monitor respiratory effort.
  4. Elevate the head of the bed to a semi-Fowler's position, align the client on the operative right side, and encourage deep breathing.Answer

Answer

Elevate the head of the bed to a semi-Fowler's position, align the client on the operative right side, and encourage deep breathing.
The client is experiencing uncompensated respiratory acidosis secondary to post-operative hypoventilation. The most effective non-pharmacological intervention is to improve lung expansion. Following a pneumonectomy, it is critical to position the client on their back or on the operative side (in this case, the right side). This positioning gravity-pools fluids into the empty surgical space and allows the remaining lung unrestricted movement to expand and improve gas exchange.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) results.
The client has a low pH (7.31) and an elevated PaCO2 (52 mm Hg) with normal bicarbonate (25 mEq/L), indicating uncompensated respiratory acidosis due to hypoventilation.
Accurate ABG interpretation determines whether the client's deterioration is respiratory or metabolic in origin.
2
Determine the priority intervention for post-operative respiratory acidosis.
The primary goal is to improve ventilation and gas exchange through positioning and deep breathing.
Hypoventilation from anesthesia and incisional pain must be countered mechanically before considering pharmacological interventions.
3
Identify the safe positioning parameters specifically for a post-pneumonectomy client.
The client must be positioned on the back or on the operative side.
Lying on the operative side ensures that fluid stays in the empty hemothorax and allows the solitary remaining lung to fully expand without compression.

Key Concept

Post-Pneumonectomy Positioning and Respiratory Acidosis Management
Estimated Time:1m 30s
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Topics

Reduction of Risk Potential

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