A nurse is caring for a patient with acute asthma exacerbation who presents with the following arterial blood gas (ABG) results: pH 7.28, PaCO2 50 mmHg, HCO3- 24 mEq/L, PaO2 60 mmHg. The patient appears anxious and has wheezing with tachypnea at 30 breaths per minute. What is the priority nursing intervention?
1Administer high-flow oxygen at 15 L/min via non-rebreather mask
2Encourage deep breathing and coughing exercises every 2 hours
3Position the patient in high Fowler's position and prepare for possible mechanical ventilation✓ 정답
4Administer sodium bicarbonate as ordered to correct the acidosis
해설
The ABG indicates compensated respiratory acidosis with hypoxemia. The drowsiness and shallow respirations (10/min) suggest CO2 narcosis, making positioning in high Fowler's and preparing for mechanical ventilation the priority to optimize ventilation and prevent respiratory failure. Other options are less immediate or inappropriate.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with an acute asthma exacerbation and deteriorating Arterial Blood Gas (ABG) values. The core theme is recognizing Acute Respiratory Failure and impending Respiratory Arrest. The ABG shows: pH 7.28 (Acidosis), PaCO2 50 mmHg (Hypercapnia), PaO2 60 mmHg (Hypoxemia). This is uncompensated respiratory acidosis because the HCO3- is normal (24 mEq/L), indicating the kidneys have not had time to compensate. The patient's anxiety, wheezing, and tachypnea (30/min) are signs of severe respiratory distress and increased work of breathing.
Answer Rationale: Key Point! The priority is to optimize ventilation and prepare for advanced airway management. Positioning in High Fowler's maximizes lung expansion and eases the work of breathing. "Preparing for possible mechanical ventilation" is critical because the patient's ABG and clinical presentation (uncompensated respiratory acidosis with hypoxemia despite tachypnea) indicate that non-invasive efforts may fail. The nurse must anticipate the need for intubation and mechanical ventilation to support the failing respiratory system.
Distractor Analysis:
Watch out for confusion! Option ①: Administering high-flow oxygen is important for hypoxemia, but in a patient with CO2 retention (high PaCO2), uncontrolled high-flow oxygen can suppress the hypoxic drive to breathe, potentially worsening hypercapnia and respiratory acidosis. Oxygen should be administered cautiously and titrated to a target SpO2 (e.g., 88-92% in some COPD/asthma protocols).
Option ②: Encouraging deep breathing and coughing is a general pulmonary hygiene measure but is not the priority during an acute, severe exacerbation. The patient is in distress and may not be able to cooperate effectively.
Option ④: Administering sodium bicarbonate is incorrect. Sodium bicarbonate is used to correct metabolic acidosis, not respiratory acidosis. The primary treatment for respiratory acidosis is to improve ventilation, not to buffer the acid chemically. Giving bicarbonate can lead to complications like metabolic alkalosis and fluid overload.
Related Concepts: This scenario integrates ABG interpretation, asthma pathophysiology (bronchoconstriction, air trapping), the nursing process (prioritizing airway and breathing), and collaboration with the respiratory therapy and medical team for advanced care.
Concept Summary
Physiology: In asthma, bronchoconstriction and inflammation increase airway resistance. The patient breathes rapidly (tachypnea) to try to maintain minute ventilation, but this can lead to air trapping (increased residual volume) and ultimately fatigue, resulting in hypoventilation and CO2 retention (hypercapnia).
Pharmacology: First-line drugs for acute asthma are short-acting beta-agonists (SABAs) like albuterol and systemic corticosteroids. The question implies these are being given, but the patient is still deteriorating, necessitating escalation of care.
ROME: Respiratory Opposite, Metabolic Equal. Remember: In Respiratory disorders, pH and PaCO2 move in Opposite directions (High PaCO2 → Low pH = Acidosis). In Metabolic disorders, they move in the Equal direction (Low HCO3- → Low pH).
ABCs for Priority: Always think Airway, Breathing, Circulation first. Preparing for mechanical ventilation is a high-level "B" intervention.
O2 Caution Mnemonic: "CO2 retainers get LOW flow" (for chronic conditions like COPD). In acute asthma, titrate O2 to target saturation, avoiding unnecessary high concentrations.
High-Frequency NCLEX Topics
This integrates several high-yield NCLEX areas: ABG interpretation, prioritization (ABCs), asthma management, and medication knowledge (knowing when NOT to give a drug like bicarbonate). NCLEX loves to test the nurse's ability to recognize a deteriorating patient and take the correct immediate action.
Watch Out for Question Variations!
Symptom Focus: Instead of asking for the intervention, a question might ask: "The nurse identifies which finding as indicative of respiratory failure in a patient with asthma?" (Answer: Uncompensated respiratory acidosis on ABG, somnolence, inability to speak in full sentences).
Medication Focus: "Which medication should the nurse anticipate administering first to this patient?" (Answer: A short-acting inhaled beta-agonist like albuterol).
Assessment Focus: "Which assessment finding requires immediate intervention by the nurse?" (Answer: A decreasing respiratory rate after a period of tachypnea, which may signal impending respiratory arrest due to fatigue).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a medical-surgical unit. Your patient, Mr. Jones, a 35-year-old with a history of asthma, was admitted 6 hours ago for an exacerbation. He received nebulized albuterol/ipratropium and IV methylprednisolone. You notice he is increasingly anxious, sitting upright, using accessory muscles to breathe, and his SpO2 is 89% on 4L nasal cannula. You immediately call for help and obtain an ABG.
Nursing Intervention Strategy:
Immediate Assessment (ABCs): Assess airway patency, respiratory rate/effort/pattern, auscultate lung sounds (wheezing? silent chest?), check SpO2, and note level of consciousness (anxiety can progress to lethargy).
Positioning: Assist the patient into High Fowler's position or have them lean forward on an overbed table (tripod position) to maximize lung expansion.
Oxygen Therapy: Based on the ABG showing hypoxemia, you would titrate oxygen upward to achieve a target SpO2 (e.g., 92-95%), likely using a non-rebreather mask, while closely monitoring for any decrease in respiratory drive. The order in option ① (15 L/min) is too rigid and non-titrated.
Collaboration & Preparation: Notify the rapid response team or physician STAT. Gather emergency airway equipment (suction, bag-valve-mask, intubation tray) at the bedside. Prepare medications that may be needed for rapid sequence intubation (RSI).
Ongoing Monitoring: Continuously monitor vital signs, respiratory status, and ABG trends. Provide calm, clear reassurance to the anxious patient.
Patient Safety and Precautions:
Never leave a patient in severe respiratory distress alone.
Medication Caution: Know that sedatives are generally contraindicated as they can further depress respiration.
Communication: Use simple, direct communication. A patient who cannot speak in full sentences is in severe distress.
Nursing Procedure & Medication FlowProcedure: Preparing for Possible Intubation & Mechanical Ventilation
Ensure crash cart/airway cart is accessible.
Set up suction (Yankauer) and test it.
Check the bag-valve-mask (BVM) device and connect to oxygen source.
Open the intubation tray per facility protocol (ensure laryngoscope blades, endotracheal tubes of various sizes, stylet, syringe for cuff inflation are ready).
Have emergency medications drawn up and labeled as per team request (e.g., etomidate, succinylcholine).
Document all actions, assessments, and communications accurately and in real-time.
Nursing Considerations: Monitor for hyperglycemia, mood changes, GI upset. It is a cornerstone treatment for asthma exacerbations but its effect is not immediate (takes hours).
A Word from Your Senior Nurse
"In moments like this, your knowledge and calm demeanor are your greatest tools. Recognizing that a wheezing patient who suddenly becomes quiet or whose respiratory rate drops is a critical emergency—not an improvement—is a lifesaving skill. On the NCLEX and in practice, always link the lab value (the ABG) to the patient's clinical picture. Don't just memorize 'pH low = acidosis.' Ask yourself: 'What is this telling me about my patient's ability to breathe right now, and what is the most effective action I can take to support them?' That's the thinking of a true nurse."
Arterial Blood Gas — A test that measures the acidity (pH) and levels of oxygen and carbon dioxide in arterial blood; critical for assessing respiratory and metabolic status.
Respiratory Acidosis — A condition characterized by a blood pH < 7.35 due to inadequate alveolar ventilation (hypoventilation), leading to retention of carbon dioxide (PaCO2 > 45 mmHg).
High Fowler's Position — A patient position where the head of the bed is raised to 60-90 degrees; promotes lung expansion and eases breathing in patients with respiratory distress.
Hypoxic Drive — A secondary stimulus for breathing in some patients with chronic hypercapnia, where low blood oxygen (PaO2) rather than high carbon dioxide (PaCO2) is the main respiratory trigger.
Status Asthmaticus — A severe, life-threatening asthma attack that is unresponsive to standard bronchodilator therapy and may lead to respiratory failure.