During the continuous monitoring of a client admitted with a severe asthma exacerbation, t… — NCLEX-RN

During the continuous monitoring of a client admitted with a severe asthma exacerbation, the nurse observes that the client's respiratory rate has abruptly declined from 36 to 10 breaths per minute. The previously auscultated loud wheezes are now markedly diminished, and the client is increasingly somnolent. Recent arterial blood gas (ABG) analysis reveals the following results:

Parameter	Value
pH	7.24
$PaCO_2$	72 mm Hg
$PaO_2$	56 mm Hg
$HCO_3^-$	24 mEq/L

What is the most critical action for the nurse to take?

Activate the rapid response team and prepare for emergent endotracheal intubationCevap
B
Apply a non-rebreather mask at 15 liters per minute to correct the oxygenation deficit
C
Administer the prescribed intravenous methylprednisolone to reduce airway inflammation
D
Initiate a rapid isotonic intravenous fluid bolus to treat impending circulatory collapse

Cevap

Activate the rapid response team and prepare for emergent endotracheal intubation

The correct action directly addresses the life-threatening emergency. The client is experiencing a 'silent chest' and severe uncompensated respiratory acidosis, indicating acute respiratory failure. Because the client is exhausted and losing consciousness (somnolent) due to high carbon dioxide levels, immediate endotracheal intubation and mechanical ventilation are required to save their life.

Adım Adım Çözüm

Analyze the physical assessment findings.

The drop in respiratory rate (from 36 to 10), decreased wheezing ('silent chest'), and somnolence indicate that the client is exhausted and can no longer maintain the work of breathing.

Recognizing a 'silent chest' in asthma is critical because it indicates airflow is so restricted that wheezing can no longer be produced, signaling imminent respiratory arrest.

Interpret the arterial blood gas (ABG) values.

pH of 7.24 (acidosis),

PaCO_2

of 72 mm Hg (hypercapnia), and

HCO_3^-

of 24 mEq/L (normal) reveal uncompensated respiratory acidosis.

High

PaCO_2

confirms that the client is failing to ventilate and is retaining carbon dioxide, which directly correlates with the clinical finding of somnolence (CO2 narcosis).

Prioritize the required nursing interventions.

Advanced airway management via endotracheal intubation and mechanical ventilation is selected as the top priority.

According to the ABCs (Airway, Breathing, Circulation), a failing airway and inability to breathe autonomously require immediate mechanical support to prevent cardiac arrest.

Anahtar Kavram

Recognition and immediate management of impending respiratory failure (status asthmaticus).

Soru

Cevap

Adım Adım Çözüm

Anahtar Kavram

Sık Yapılan Hatalar

Konular

Bu konudan daha fazla soru