A nurse is caring for an adult client who is receiving mechanical ventilation for acute re… — NCLEX-RN

A nurse is caring for an adult client who is receiving mechanical ventilation for acute respiratory failure. The client is currently positioned flat and supine in bed. The most recent arterial blood gas (ABG) results reveal a $\text{pH}$ of $7.28$ , $\text{PaCO}_2$ of $58 \text{ mm Hg}$ , $\text{PaO}_2$ of $62 \text{ mm Hg}$ , and $\text{HCO}_3^-$ of $24 \text{ mEq/L}$ . Which of the following nursing actions should be prioritized to reduce the client's risk for physiological decompensation?

Elevating the head of the bed to between $30$ and $45$ degreesCevap
B
Administering a prescribed intravenous bolus of sodium bicarbonate
C
Placing the client in the Trendelenburg position to facilitate postural drainage
D
Increasing the continuous intravenous fluid infusion rate

Cevap

Elevating the head of the bed to between

30

and

45

degrees

The arterial blood gas values indicate uncompensated respiratory acidosis (

\text{pH}

7.28

\text{PaCO}_2

58 \text{ mm Hg}

) combined with hypoxemia (

\text{PaO}_2

62 \text{ mm Hg}

). Lying flat severely restricts diaphragmatic excursion and decreases lung compliance. By elevating the head of the bed to between

30

and

45

degrees, gravity shifts the abdominal organs downward, thereby promoting optimal lung expansion, decreasing the work of breathing, and facilitating the clearance of retained carbon dioxide. Furthermore, this positioning is a critical standard of care to reduce the risk of ventilator-associated pneumonia (VAP) in intubated clients.

Adım Adım Çözüm

Analyze the arterial blood gas (ABG) results to determine the primary physiological imbalance.

The

\text{pH}

is low (

7.28

\text{PaCO}_2

is high (

58 \text{ mm Hg}

), and

\text{HCO}_3^-

is normal (

24 \text{ mEq/L}

), indicating uncompensated respiratory acidosis.

Accurate ABG interpretation is essential to determine whether the client's deterioration is respiratory or metabolic in origin.

Evaluate the impact of the client's current positioning on their respiratory status.

The client is lying flat and supine, a position that restricts lung expansion and diaphragm movement.

A flat position reduces functional residual capacity and worsens carbon dioxide retention in mechanically ventilated clients.

Select the intervention that most directly mitigates the identified respiratory risk.

Elevating the head of the bed to

30-45

degrees is prioritized.

This positioning utilizes gravity to pull abdominal organs away from the diaphragm, maximizing lung expansion, improving gas exchange, and serving as a primary measure to prevent ventilator-associated pneumonia.

Anahtar Kavram

Risk Reduction via Proper Positioning in Respiratory Acidosis

Soru

Cevap

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