A 45-year-old client is receiving mechanical ventilation in the intensive care unit following severe chest trauma. The morning arterial blood gas (ABG) results reveal a of , of mm Hg, of mEq/L, and of mm Hg. The client is becoming increasingly restless, and the ventilator's high-pressure alarm is sounding continuously. Which action should the nurse take first to reduce the client's risk of further physiological decompensation?
- Suction the endotracheal tube to clear potential airway secretionsCevap
- BAdminister the prescribed intravenous sedative to reduce client agitation
- CLower the head of the bed to a flat, supine position to equalize gas exchange
- DDocument the findings as fully compensated respiratory acidosis and continue monitoring
Cevap
Suction the endotracheal tube to clear potential airway secretions.
The client's ABG results indicate acute, uncompensated respiratory acidosis paired with hypoxemia. A high-pressure ventilator alarm, especially when accompanied by sudden restlessness, strongly suggests an acute airway obstruction. This is frequently caused by accumulated secretions or the client biting the endotracheal tube. Suctioning directly addresses the most imminent threat to the client's physiological integrity by clearing the airway, reducing resistance, and restoring adequate ventilation.
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Anahtar Kavram
Airway management and interpretation of mechanical ventilator alarms to prevent respiratory failure.