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Difficulty: HardPhysiological Adaptation

A registered nurse is evaluating a client being treated for severe bacterial pneumonia. Over the past hour, the client has become visibly agitated and restless. Current assessment parameters include a heart rate of 118 beats per minute, a respiratory rate of 32 breaths per minute, and cool, diaphoretic extremities. Arterial blood gas (ABG) analysis on room air yields the following: pH 7.50, PaCO2 26 mm Hg, PaO2 54 mm Hg, and HCO3 22 mEq/L. Which of the following is the priority nursing intervention?

  1. A
    Coach the client to perform pursed-lip breathing exercises to lower the blood pH
  2. B
    Administer a prescribed as-needed intravenous sedative to manage the acute agitation
  3. Apply a non-rebreather mask with high-flow oxygen and immediately notify the rapid response teamAnswer
  4. D
    Document the vital signs as an expected compensatory response and repeat the assessment in one hour

Answer

Apply a non-rebreather mask with high-flow oxygen and immediately notify the rapid response team.
The client's clinical presentation indicates acute respiratory failure and early compensatory shock, evidenced by severe hypoxemia (PaO2 54 mm Hg), tachycardia, tachypnea, agitation, and cool, diaphoretic skin. The respiratory alkalosis (pH 7.50, PaCO2 26 mm Hg) is a consequence of the client hyperventilating in a physiological attempt to increase oxygen intake. The immediate priority is to correct the severe hypoxemia with high-flow oxygen and escalate care by notifying the rapid response team to prevent further decompensation.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) values.
The pH of 7.50 indicates alkalemia. The PaCO2 of 26 mm Hg indicates a respiratory origin. The PaO2 of 54 mm Hg reveals severe hypoxemia.
Identifying the primary acid-base imbalance and oxygenation status is essential for accurate clinical judgment.
2
Correlate the ABG results with the physical assessment findings.
The tachypnea (32 breaths/min) is causing the respiratory alkalosis. The agitation, tachycardia, and cool, diaphoretic skin are classic early signs of hypoxia and compensatory shock.
Lab values must always be interpreted in the context of the client's systemic physiological presentation.
3
Determine the underlying pathophysiology driving the client's deterioration.
The hyperventilation is a physiological attempt to compensate for the severe, life-threatening hypoxemia.
Treating the root cause (hypoxemia) rather than the compensatory mechanism (hyperventilation) is critical for survival.
4
Select the highest priority nursing intervention.
The client requires immediate high-flow oxygen administration and escalation of care via the rapid response team.
Airway and Breathing take absolute precedence in an unstable, rapidly deteriorating client.

Key Concept

Recognizing early physiological signs of shock and severe hypoxemia alongside accurate ABG interpretation.
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Topics

Physiological Adaptation

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