A client admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) is intubated and placed on assist-control mechanical ventilation. When suctioning pulmonary secretions from the endotracheal tube (ETT) using a closed suction system, which action should the nurse implement to ensure that the client receives adequate oxygenation?

A. Allow the family to touch and talk to the client. Family presence can provide emotional support for both the client and loved ones. Even though the client is sedated and has a low GCS, familiar voices and touch may reduce stress and anxiety. Allowing family interaction fosters comfort and connection during a critical time.
B. Reassess the client's vascular access. Maintaining secure and functional vascular access is essential for administering fluids, medications, and emergency interventions. Before transport, the nurse should confirm IV patency, ensure secure connections, and assess for signs of infiltration or malfunction. Trauma patients may require additional or larger bore IV access for fluid resuscitation or transfusion.
C. Assess neurological vital signs every 15 minutes. Frequent neurological assessments are crucial in head trauma patients with a low GCS to monitor for signs of worsening intracranial pressure, cerebral edema, or herniation. Changes in pupil response, motor function, or vital signs may indicate neurological deterioration requiring urgent intervention. Monitoring trends over time is necessary for early detection of complications.
D. Administer ophthalmic ointment. Clients with a low GCS often have impaired blinking, placing them at risk for corneal abrasions and dryness. Applying ophthalmic lubricant or artificial tears protects the cornea from injury and promotes eye health. Preventing exposure keratitis is essential in unconscious or sedated clients to avoid long-term ocular damage.
E. Apply soft bilateral wrist restraints for transport. Restraints are unnecessary because the client is sedated, intubated, and has a GCS of 6, meaning they cannot attempt self-extubation or interfere with care. Restraints should only be used if the client demonstrates a risk of harm. Standard transport protocols prioritize sedation and safety measures over restraints unless specifically required.

Answer:

Potential Condition:

Acute Adrenal Crisis

• The client has a history of Addison’s disease (chronic steroid use) and recent illness with vomiting, leading to decreased oral intake and medication noncompliance.
• Symptoms such as hypotension (80/50 mmHg), tachycardia (115 bpm), confusion, nausea, vomiting, and abdominal pain are classic signs of acute adrenal insufficiency.

Actions to Take:

Bolus Intravenous Fluids

• Fluid resuscitation with 0.9% normal saline is critical to restore intravascular volume and correct hypotension due to adrenal insufficiency.

Check Blood Glucose

• Hypoglycemia is a common complication of adrenal crisis due to cortisol deficiency, requiring close monitoring and possible glucose administration.

Parameters to Monitor:

Blood Pressure

• Hypotension is a hallmark of adrenal crisis and must be monitored closely to assess response to fluid resuscitation and steroid therapy.

Electrolytes

• Clients with adrenal crisis often have hyponatremia and hyperkalemia due to aldosterone deficiency, requiring frequent electrolyte monitoring.

Incorrect Choices:

Potential Conditions:

• Ketoacidosis: More common in diabetes, presents with high blood glucose and ketonuria.
• Diabetes Insipidus: Causes polyuria and dehydration but lacks hypotension and hyperkalemia.
• Myxedema: Linked to hypothyroidism, causing bradycardia and hypothermia, not hypotension and hyperkalemia.

Actions to Take:

• Hold hydrocortisone dose: Steroid replacement is necessary, not withholding it.
• Collect urine for a urinalysis: Not a priority; adrenal crisis is diagnosed via history, symptoms, and labs.
• Change intravenous fluids to 0.45%: Hypotension requires 0.9% normal saline, not hypotonic fluids.

Parameters to Monitor:

• Urine output: Useful but less critical than blood pressure and electrolytes in adrenal crisis.
• Thyroid stimulating hormone: Relevant for hypothyroidism, not adrenal insufficiency.
• Heart rate: Tachycardia is expected but is not the most critical indicator of improvement.