A nurse is caring for a client with a history of severe chronic obstructive pulmonary dise… — NCLEX-RN

A nurse is caring for a client with a history of severe chronic obstructive pulmonary disease (COPD) who was admitted for community-acquired pneumonia. The client is currently receiving oxygen at $2 \text{ L/min}$ via nasal cannula. The most recent arterial blood gas (ABG) results reveal a $pH$ of $7.28$ , $PaCO_2$ of $64 \text{ mm Hg}$ , $HCO_3^-$ of $30 \text{ mEq/L}$ , and $PaO_2$ of $56 \text{ mm Hg}$ . The client's vital signs are blood pressure $86/54 \text{ mm Hg}$ , heart rate $118 \text{ bpm}$ , and respiratory rate $28 \text{ breaths/min}$ . Which of the following actions should the nurse prioritize to reduce the risk of further physiological decompensation? Select all that apply.

Prepare the client for potential endotracheal intubation and mechanical ventilation.Cevap
Administer a prescribed intravenous fluid bolus to address the vital sign abnormalities.Cevap
C
Place the client in a supine position with the legs elevated to treat the hypotension.
D
Administer prescribed intravenous sodium bicarbonate to correct the acid-base imbalance.
Perform a focused neurological assessment to evaluate for carbon dioxide narcosis.Cevap
F
Delegate the immediate collection of a sputum culture to the unlicensed assistive personnel (UAP).

Cevap

The correct actions are preparing for potential intubation, administering a prescribed fluid bolus, and performing a focused neurological assessment.

The client is experiencing acute-on-chronic respiratory failure with respiratory acidosis and signs of early shock. Preparing for intubation directly addresses the respiratory failure. Administering an intravenous fluid bolus addresses the hypotension and tachycardia indicative of shock. Performing a neurological assessment monitors for life-threatening complications of severe hypercapnia, such as

CO_2

narcosis.

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Analyze the ABG results.

The

pH

7.28

indicates acidosis. The elevated

PaCO_2

(

64 \text{ mm Hg}

) indicates a respiratory origin. This acute-on-chronic respiratory failure requires immediate advanced airway preparation.

Identifying the primary physiological derangement guides initial life-saving interventions.

Analyze the vital signs.

A blood pressure of

86/54 \text{ mm Hg}

and a heart rate of

118 \text{ bpm}

indicate impending shock, requiring immediate volume resuscitation.

Hypotension and tachycardia in the presence of an infection (pneumonia) suggest sepsis and inadequate tissue perfusion.

Evaluate the proposed positioning intervention.

Placing the client supine is contraindicated.

While leg elevation helps hypotension, the supine position restricts diaphragmatic excursion and worsens gas exchange in a client already in respiratory failure.

Evaluate the proposed pharmacological intervention.

Sodium bicarbonate is contraindicated.

The client has respiratory acidosis. Administering bicarbonate generates additional

CO_2

, which the client cannot exhale, thus worsening the acidosis.

Evaluate the delegation task.

The sputum collection cannot be delegated.

The client is hemodynamically and physically unstable; the RN must perform or directly oversee all care to monitor for sudden clinical changes.

Anahtar Kavram

Reduction of risk potential in a hemodynamically unstable client with acute respiratory failure involves prioritizing airway management, fluid resuscitation, and continuous RN assessment while avoiding contraindicated interventions.

Soru

Cevap

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