A nurse is assessing a client admitted with severe acute kidney injury (AKI). During the morning assessment, the client is alert, restless, and exhibiting deep, rapid respirations at a rate of breaths/minute. The client's oxygen saturation is on room air. The most recent arterial blood gas (ABG) values are: , mm Hg, mm Hg, and mEq/L. Which of the following is the priority nursing action?
- AAdminister a prescribed intravenous sedative to reduce the client's work of breathing and restlessness.
- BPrepare the client for immediate endotracheal intubation to treat impending respiratory failure.
- Continue to monitor the client closely, recognizing the respiratory pattern as an expected compensatory mechanism.Cevap
- DInitiate continuous cardiac monitoring and assess for narrowing pulse pressure indicative of early shock.
Cevap
The correct priority action is to continue monitoring the client closely, recognizing the deep and rapid respiratory pattern as an expected physiological compensatory mechanism.
The client's arterial blood gas (ABG) results demonstrate metabolic acidosis (low , low ) with partial respiratory compensation (low ). In the setting of severe acute kidney injury, the kidneys are unable to excrete hydrogen ions, leading to metabolic acidosis. The body compensates by stimulating the respiratory center to increase the depth and rate of breathing (Kussmaul respirations) in order to blow off carbon dioxide (an acid) and raise the toward normal. Because this tachypnea is a vital physiological compensatory mechanism, the nurse should recognize it as expected and continue to monitor the client, rather than attempting to stop the rapid breathing.
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Respiratory compensation (Kussmaul respirations) for metabolic acidosis