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Soru

Zorluk: OrtaReduction of Risk Potential

An adult client in the intensive care unit is undergoing a spontaneous breathing trial (SBT) via continuous positive airway pressure (CPAP) to evaluate readiness for extubation. After 30 minutes, the client becomes severely restless, diaphoretic, and exhibits increased accessory muscle use. Arterial blood gas (ABG) analysis reveals a pH of 7.297.29, a PaCO 2_2 of 5656 mm Hg, a PaO 2_2 of 6464 mm Hg, and an HCO 3−_3^- of 2525 mEq/L. Which action is the priority for the nurse to take?

  1. A
    Reposition the client into a flat, recumbent posture to promote venous return and improve cerebral oxygenation.
  2. B
    Administer a prescribed low-dose intravenous benzodiazepine to alleviate the client's severe restlessness.
  3. Terminate the weaning trial, resume full mechanical ventilatory support, and notify the healthcare provider.Cevap
  4. D
    Increase the fraction of inspired oxygen (FiO2) on the CPAP setting and continue the trial for another 15 minutes.

Cevap

Terminate the weaning trial, resume full mechanical ventilatory support, and notify the healthcare provider.
The correct answer addresses both the clinical presentation (restlessness, accessory muscle use) and the diagnostic data (uncompensated respiratory acidosis and hypoxemia). These findings confirm that the client is failing the spontaneous breathing trial and cannot maintain adequate ventilation independently. Reconnecting the client to the mechanical ventilator is the essential action to reduce the risk of impending respiratory arrest.

Adım Adım Çözüm

1
Analyze the arterial blood gas (ABG) results.
The ABG shows uncompensated respiratory acidosis (pH 7.297.29, elevated PaCO 2_2 5656 mm Hg, normal HCO 3−_3^- 2525 mEq/L) accompanied by hypoxemia (PaO 2_2 6464 mm Hg).
Identifying the acid-base imbalance determines the physiological state of the client's respiratory function.
2
Evaluate the clinical manifestations.
Restlessness, diaphoresis, and accessory muscle use are critical indicators of hypoxia, hypercapnia, and severe muscle fatigue.
Correlating lab data with physical assessment confirms that the client is failing the spontaneous breathing trial.
3
Determine the priority risk reduction intervention.
The nurse must immediately halt the trial and provide full ventilatory support.
Delaying mechanical support or masking symptoms with sedatives can lead to total respiratory arrest.

Anahtar Kavram

Identifying signs of weaning failure and applying appropriate interventions to reduce the risk of respiratory arrest.
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Konular

Reduction of Risk Potential

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