Select appropriate nursing actions when caring for clients with chest tubes. Select all that apply.

Rationale:

A. Nasogastric suctioning removes gastric contents, including hydrochloric acid. This loss of acid can lead to metabolic alkalosis, not respiratory acidosis, because it affects the bicarbonate-to-acid balance in the blood. It does not interfere with CO2 retention or the respiratory process, so it does not directly cause respiratory acidosis.

B. Sedatives, including benzodiazepines, barbiturates, or opioids, can depress the central respiratory center in the brainstem. When the respiratory drive is suppressed, the patient breathes more slowly or shallowly, resulting in hypoventilation. Hypoventilation leads to CO2 retention, which combines with water to form carbonic acid, lowering blood pH and causing respiratory acidosis. This is a common scenario in overdose situations, particularly in older adults or patients with pre-existing lung disease.

C. CNS depression can result from head trauma, stroke, tumors, or other neurologic disorders that impair the brain’s ability to regulate breathing. Like sedative overdose, CNS depression reduces respiratory drive, leading to inadequate alveolar ventilation, CO2 accumulation, and respiratory acidosis. This is why monitoring respiratory rate, depth, and ABGs is critical in patients with CNS compromise.

D. Diabetic ketoacidosis (DKA) causes metabolic acidosis due to the accumulation of ketone bodies, not respiratory acidosis. Patients with DKA usually hyperventilate (Kussmaul respirations) as a compensatory mechanism to blow off CO2 and partially correct the acidosis. Therefore, DKA predisposes to metabolic, not respiratory, acid-base disturbances.

E. Anxiety and fear typically lead to hyperventilation, in which the patient breathes rapidly and deeply. This causes excessive CO2 elimination, lowering PaCO2 and resulting in respiratory alkalosis, the opposite of respiratory acidosis.

Rationale:

A. Notify the healthcare provider is incorrect as the first action. While the provider must be informed of potential ETT displacement, immediate assessment of the patient’s airway and lung sounds is the priority to ensure safety.

B. Obtain a STAT chest x-ray is incorrect as the first action. A chest x-ray is important for confirming tube placement, but you must first assess for clinical signs of airway compromise or hypoxia before imaging. Waiting for a chest x-ray could delay intervention if the tube has entered a mainstem bronchus.

C. Give the client something for anxiety is incorrect because the anxiety may be a response to hypoxia or airway obstruction, not a primary anxiety issue. Administering medication without assessing the underlying cause could delay critical intervention.

D. Listen to the client's lungs is correct. The first action is to assess breath sounds bilaterally to determine whether the tube has migrated into a mainstem bronchus, which typically causes absent or diminished breath sounds on one side. Immediate assessment of ventilation and oxygenation guides urgent interventions, such as repositioning the ETT, providing oxygen, or calling for help.