A patient presents with a diagnosis of chronic obstructive pulmonary disease (COPD). The ABG results are as follows: pH 7.32. pCO2 68, p02 78, HCO3 23. What action should the nurse take first?
Remove the client's 02 mask.
Notify the physician
Have the client breath into a paper bag
Place the patient in left side-lying position
The Correct Answer is B
A. Remove the client's O₂ mask: Removing supplemental oxygen is unsafe and may worsen hypoxia. Even though oxygen must be carefully titrated in COPD, abrupt removal is never appropriate without medical direction, especially when the client is already hypoxemic.
B. Notify the physician: The ABG shows respiratory acidosis (low pH, elevated pCO₂) with insufficient compensation and potential respiratory failure. Immediate provider notification is warranted to adjust oxygen delivery, initiate or escalate respiratory support, or evaluate for further interventions.
C. Have the client breathe into a paper bag: Paper bag breathing is used for respiratory alkalosis caused by hyperventilation, not for respiratory acidosis. This action would further elevate CO₂ and worsen the client's acid-base status.
D. Place the patient in left side-lying position: Side-lying positioning does not address the critical issue of respiratory acidosis. Instead, placing the client in high Fowler’s position might help improve ventilation, but first the provider must be notified to address the urgent ABG findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Status epilepticus:This refers to a prolonged or repeated seizure without recovery of consciousness between episodes. It is unrelated to respiratory conditions and does not apply to Lily’s worsening asthma symptoms.
B. Status asthmaticus:Status asthmaticus is a severe, prolonged asthma attack that does not respond to initial bronchodilator therapy. Lily’s persistent wheezing, increased work of breathing, and low oxygen saturation despite treatment indicate this potentially life-threatening condition that requires immediate medical intervention.
C. Postictal status:The postictal state follows a seizure and is characterized by confusion or fatigue. It has no relevance to Lily’s presentation, which involves respiratory, not neurological, distress.
D. Status post asthma:This phrase describes a condition following an asthma episode but does not reflect an ongoing or worsening attack. It is not a recognized clinical term for an acute, unresponsive asthma condition.
Correct Answer is C
Explanation
A. Normal temperature:A temperature of 98.6°F (37°C) is within the normal range and does not contribute to the assessment of asthma severity. It helps rule out infection but does not reflect worsening respiratory status.
B. Slightly elevated heart rate:A heart rate of 122 bpm is elevated for a 7-year-old and may indicate respiratory distress or anxiety. However, it is a nonspecific finding and not the strongest indicator of worsening asthma.
C. Nasal flaring and intercostal retractions:These are classic signs of increased work of breathing and indicate significant respiratory distress. They reflect worsening airway obstruction and the need for immediate intervention to prevent further deterioration.
D. Use of maintenance inhaler:Use of a maintenance inhaler such as fluticasone is part of routine asthma management and does not indicate worsening symptoms. It is a preventive measure, not a reflection of acute status.
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