A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min via nasal cannula. The following clinical data are available:
Arterial Blood Gases
Vital Signs
pH = 7.28
Pulse rate = 96 beats/min
PaO2 = 85 mm Hg
Blood pressure = 135/45
PaCO2 = 55 mm Hg
Respiratory rate = 6 breaths/min
HCO3- = 26 mEq/L
O2 saturation = 88%
Which action should the nurse take first?
a.
Notify the Rapid Response Team and provide ventilation support.
b.
Change the nasal cannula to a mask and reassess in 10 minutes.
c.
Place the client in Fowler's position if he or she is able to tolerate it.
d.
Decrease the flow rate of oxygen to 2 to 4 L/min, and reassess.
ANS: A
The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased arterial oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case, eventually causing respiratory arrest and death. The nurse could decrease the oxygen flow rate; eventually, this might improve the client's respiratory rate, but the priority action would be to call the Rapid Response Team whenever a client with chronic carbon dioxide retention has a respiratory rate less than 10 breaths/min. Changing the cannula to a mask does nothing to improve the client's hypoxic drive, nor would it address the client's most pressing need. Positioning will not help the client breathe at a normal rate or maintain client safety.
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