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Difficulty: MediumReduction of Risk Potential

A 68-year-old client with a history of severe chronic obstructive pulmonary disease (COPD) is admitted for an acute exacerbation. The nurse notes that the client has become increasingly lethargic over the past hour. The most recent arterial blood gas (ABG) results reveal a pH of 7.26, a PaCO2PaCO_2 of 68 mm Hg, and an HCO3−HCO_3^- of 25 mEq/L. To minimize the risk of respiratory arrest, which of the following actions should the nurse take first?

  1. A
    Administer intravenous sodium bicarbonate to neutralize the underlying metabolic acidosis.
  2. B
    Position the client flat in a supine position to ensure an unobstructed upper airway.
  3. Prepare to initiate noninvasive positive pressure ventilation to improve alveolar clearance of carbon dioxide.Answer
  4. D
    Apply a non-rebreather mask at 15 L/min of oxygen to rapidly resolve the client's tissue hypoxia.

Answer

The nurse should prepare to initiate noninvasive positive pressure ventilation to improve alveolar clearance of carbon dioxide.
The client's ABG reveals uncompensated respiratory acidosis (pH 7.26, PaCO2PaCO_2 68 mm Hg). The increasing lethargy is a sign of carbon dioxide narcosis, indicating impending respiratory failure. Noninvasive positive pressure ventilation is the priority intervention because it directly improves alveolar ventilation, allowing the client to exhale retained CO2CO_2 and correct the severe acid-base imbalance.

Step-by-Step Solution

1
Analyze the arterial blood gas (ABG) values.
pH 7.26 indicates acidemia. PaCO2PaCO_2 68 mm Hg indicates respiratory acidosis. HCO3−HCO_3^- 25 mEq/L is normal.
To identify the primary acid-base imbalance.
2
Correlate the ABG results with the clinical presentation.
The client is experiencing uncompensated respiratory acidosis with lethargy.
Lethargy in a client with severe COPD and a high PaCO2PaCO_2 strongly indicates carbon dioxide narcosis and impending respiratory failure.
3
Determine the priority risk reduction intervention.
Select noninvasive positive pressure ventilation (e.g., BiPAP).
BiPAP assists with ventilation, helping to blow off excess CO2CO_2 and reverse the hypercapnic encephalopathy.

Key Concept

In clients with severe COPD, acute retention of carbon dioxide leads to respiratory acidosis and altered mental status (narcosis). The priority risk reduction intervention is to improve ventilation to facilitate the removal of carbon dioxide.
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Reduction of Risk Potential

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