An elderly patient with worsening COPD presents to the Emergency Department (ED) with fatigue and altered level of consciousness (ALOC). Upon assessment the nurse finds SpO2 saturation of 87%, and ABG: pH 7.21, CO2 of 75, and HCO3 of 24. Which immediate intervention is BEST?
Call respiratory for an Albuterol breathing treatment.
Place on BiPap machine.
Put on oxygen 1L via Nasal Cannula.
Have them breathe into a paper bag.
The Correct Answer is B
Choice A rationale
Albuterol is a short-acting beta-2 adrenergic agonist, primarily causing bronchodilation by stimulating beta-2 receptors in bronchial smooth muscle, leading to cyclic AMP production and muscle relaxation. While beneficial for bronchospasm, it does not directly address the severe hypercapnia and respiratory acidosis indicated by the patient's ABG (pH 7.21, CO2 75), which suggests significant ventilatory failure beyond simple bronchodilation.
Choice B rationale
BiPAP (Bilevel Positive Airway Pressure) provides non-invasive ventilatory support, delivering inspiratory and expiratory positive airway pressure. This improves alveolar ventilation by increasing tidal volume and reducing the work of breathing, effectively decreasing the elevated CO2 (75 mmHg, normal range 35-45 mmHg) and improving the acidotic pH (7.21, normal range 7.35-7.45) in a patient with acute hypercapnic respiratory failure exacerbated by COPD.
Choice C rationale
Administering oxygen via nasal cannula at 1 L/min may worsen hypercapnia in COPD patients with chronic CO2 retention, due to the blunting of hypoxic drive. Their primary respiratory stimulus is hypoxia, and providing supplemental oxygen can suppress this drive, further depressing ventilation and exacerbating CO2 retention, which is already dangerously high at 75 mmHg. The SpO2 of 87% (normal range 95-100%) indicates hypoxemia, but the primary issue is ventilatory failure.
Choice D rationale
Breathing into a paper bag increases the rebreathing of exhaled CO2, which is a therapeutic intervention for hyperventilation and respiratory alkalosis. In this patient, the ABG shows significant respiratory acidosis (pH 7.21, CO2 75 mmHg), meaning they are retaining too much CO2. Therefore, increasing CO2 rebreathing would exacerbate the already severe hypercapnia and acidosis, leading to further decompensation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
Placing the patient in Trendelenburg position on their left side is the priority intervention for a suspected air embolism. This position traps the air in the apex of the right ventricle, preventing it from entering the pulmonary circulation and causing a pulmonary embolism, which can be fatal. The left lateral position further aids in keeping the air bubble within the right ventricle.
Choice A rationale
Ambulation would be contraindicated as it could facilitate the movement of the air embolism through the circulatory system, potentially leading to a more severe and widespread impact, including cerebral or pulmonary embolism. The goal is to isolate and prevent the air from progressing, not to mobilize it.
Choice C rationale
Reverse Trendelenburg position elevates the head of the bed, which would cause the air embolism to travel towards the brain, increasing the risk of a cerebral air embolism, a life-threatening complication. This position is actively harmful in the context of an air embolism.
Choice D rationale
McRoberts maneuver is used in obstetrics to aid in shoulder dystocia during childbirth by hyperflexing the mother's thighs toward her abdomen. This maneuver has no physiological relevance or benefit in the management of an air embolism and would not prevent or mitigate its effects.
Correct Answer is A
Explanation
Choice A rationale
Administering oxygen via a high-flow (Non-rebreather) mask is the immediate priority due to the client's hypoxemia, indicated by an SpO2 of 92% on room air. This action directly addresses the life-threatening compromise in oxygenation, increasing the fraction of inspired oxygen (FiO2) and improving tissue perfusion. Adequate oxygenation is critical to prevent further cellular damage and organ dysfunction in an acute respiratory distress scenario. Normal SpO2 is 95-100%.
Choice B rationale
Obtaining a chest X-ray is an important diagnostic step to identify the underlying cause of absent breath sounds, such as a pneumothorax or hemothorax. However, it is not the *first* action because stabilizing the client's oxygenation and ventilation takes precedence. While imaging provides crucial information, delaying oxygen administration to perform an X-ray could worsen the client's respiratory compromise.
Choice C rationale
Preparing for chest tube insertion is a critical intervention for conditions like pneumothorax or hemothorax, which are suggested by absent breath sounds. While this may be necessary, it is a definitive treatment that follows initial stabilization. Ensuring adequate oxygenation and establishing a clear diagnosis are prerequisites before proceeding with an invasive procedure like chest tube insertion.
Choice D rationale
Initiating IV access is essential for fluid resuscitation, medication administration, and emergency interventions. However, in the hierarchy of needs for a client with acute respiratory distress, establishing an airway and ensuring adequate oxygenation are paramount. While IV access should be established promptly, it does not supersede the immediate need to address life-threatening hypoxemia.
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