A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who has developed respiratory acidosis. The client's arterial blood gas (ABG) results show: pH 7.28, PaCO2 58 mmHg, HCO3- 26 mEq/L, PaO2 68 mmHg. Which nursing intervention should the nurse implement first?
1Administer sodium bicarbonate as prescribed to correct the acidosis immediately
2Position the client in high Fowler's position and encourage pursed-lip breathing✓ 정답
3Increase the oxygen flow rate to 6 L/min via nasal cannula
4Prepare for immediate endotracheal intubation and mechanical ventilation
해설
Positioning and breathing techniques improve ventilation and CO2 elimination in COPD patients with respiratory acidosis. Other options risk worsening CO2 retention or are too invasive.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with Chronic Obstructive Pulmonary Disease (COPD) experiencing Acute Respiratory Acidosis. The ABG results confirm the diagnosis: pH 7.28 (acidotic), PaCO2 58 mmHg (elevated, indicating hypercapnia), and a normal HCO3- 26 mEq/L (normal range 22-26 mEq/L). This is an uncompensated respiratory acidosis, meaning the kidneys have not had time to retain bicarbonate to correct the pH. In COPD, the primary problem is impaired alveolar ventilation leading to CO2 retention. The priority nursing goal is to improve ventilation to blow off excess CO2.
Answer Rationale: Key Point! The first and most appropriate intervention is Positioning the client in high Fowler's position and encouraging pursed-lip breathing. High Fowler's position maximizes lung expansion by lowering the diaphragm and reducing pressure from abdominal contents. Pursed-lip breathing is a cornerstone technique for COPD patients; it slows expiration, creates back pressure to keep small airways open longer, and improves gas exchange by facilitating more complete emptying of CO2 from the alveoli. This is a non-invasive, immediate, and independent nursing action that directly addresses the pathophysiology.
Distractor Analysis:
Watch out for confusion! Option ①, administering sodium bicarbonate, is incorrect. Sodium bicarbonate is used to correct metabolic acidosis, not primary respiratory acidosis. In respiratory acidosis, giving bicarbonate can be dangerous as it may lead to metabolic alkalosis once ventilation improves and the retained CO2 is blown off.
Option ③, increasing oxygen flow rate, is a critical error in COPD management. Many COPD patients have a hypoxic drive to breathe, where their primary respiratory stimulus is low PaO2 rather than high PaCO2. Administering high-flow oxygen (like 6 L/min) can suppress this drive, leading to hypoventilation, further CO2 retention, and potentially respiratory arrest. Oxygen should be administered cautiously at low flow rates (e.g., 1-2 L/min via nasal cannula) to achieve a target SpO2 of 88-92%.
Option ④, preparing for intubation, is an invasive last resort. While the ABG shows acidosis, the PaO2 of 68 mmHg indicates mild hypoxemia. Immediate intubation is not indicated based on these values alone. The nurse should first implement conservative measures to improve ventilation.
Related Concepts: This scenario integrates ABG interpretation, the pathophysiology of COPD, principles of oxygen therapy in chronic respiratory failure, and the nursing role in managing breathing techniques. Understanding the difference between respiratory and metabolic acidosis, and between compensated and uncompensated states, is essential.Nursing Clinical Practice GuideClinical Scenario: You are assigned to Mr. Johnson, a 68-year-old with a 40-pack-year smoking history and severe COPD. He was admitted with increased shortness of breath, fatigue, and a productive cough. His respiratory rate is 28 breaths/min, shallow, and he is using accessory muscles. His SpO2 is 89% on room air.
Nursing Intervention Strategy:
Assessment: Perform a focused respiratory assessment (rate, depth, effort, lung sounds, SpO2). Review the ABG results. Assess the patient's anxiety level, as dyspnea can cause panic.
Immediate Action (First!): Assist the patient to high Fowler's position. Sit at the bedside, model calm breathing, and coach him through pursed-lip breathing: "Inhale slowly through your nose for a count of two, then exhale gently through pursed lips (like you're whistling) for a count of four."
Oxygen Therapy: Apply oxygen via nasal cannula at 2 L/min as ordered. Re-check SpO2 in 5-10 minutes, targeting 88-92%. Never arbitrarily increase the flow rate without a specific order and close monitoring.
Medication Administration: Administer prescribed bronchodilators (e.g., albuterol via nebulizer) and corticosteroids to reduce inflammation and bronchospasm.
Monitoring & Evaluation: Reassess respiratory status, vital signs, and SpO2 frequently. Monitor for signs of worsening hypercapnia (e.g., increased somnolence, headache, confusion—"CO2 narcosis"). Prepare for a follow-up ABG to evaluate the effectiveness of interventions.
Patient Safety and Precautions: The cardinal rule in COPD is avoid high-concentration oxygen in uncontrolled settings. Always be aware of the risk of oxygen-induced hypoventilation. Ensure the patient and family understand the purpose of low-flow oxygen and pursed-lip breathing.
Perform hand hygiene and verify the medication order.
Assemble the nebulizer kit, add the prescribed medication (e.g., albuterol) and saline to the cup.
Connect to an air/oxygen source. Use the prescribed oxygen flow rate (typically 6-8 L/min) to generate the mist.
Instruct the patient to place the mouthpiece between their teeth and seal their lips around it, breathing slowly and deeply through the mouth.
Encourage the patient to hold their breath for 2-3 seconds at the end of inhalation to allow medication deposition in the airways.
Monitor for therapeutic effects (easier breathing) and side effects (tachycardia, tremors).
A Word from Your Senior Nurse
"Managing a COPD exacerbation is a classic test of your nursing judgment. Remember, your first tool is not a medication or a machine—it's your ability to position, coach, and calm the patient. That high Fowler's position and pursed-lip breathing are more than just textbook answers; they are powerful, immediate interventions you control. When you see that ABG with high CO2, your brain should immediately go to 'VENTILATE, don't medicate or over-oxygenate.' This mindset saves lives and is exactly what the NCLEX wants you to demonstrate."
Chronic Obstructive Pulmonary Disease — A progressive lung disease characterized by persistent airflow limitation, usually caused by chronic bronchitis and/or emphysema. Key features include dyspnea, chronic cough, and sputum production.
Respiratory Acidosis — An acid-base imbalance characterized by a primary increase in arterial carbon dioxide (PaCO2 > 45 mmHg) and a decrease in pH (< 7.35). It is caused by alveolar hypoventilation.
Hypoxic Drive — A backup mechanism to control breathing in some severe COPD patients where the primary stimulus for respiration is low oxygen levels (PaO2) rather than high carbon dioxide levels (PaCO2). High-flow oxygen can suppress this drive.
Pursed-Lip Breathing — A breathing technique where the patient inhales through the nose and exhales slowly through pursed lips. It increases airway pressure, keeps small airways open longer, improves ventilation/perfusion matching, and reduces dyspnea.
Arterial Blood Gas — A blood test that measures the acidity (pH) and levels of oxygen (PaO2) and carbon dioxide (PaCO2) in arterial blood. It is essential for diagnosing and managing acid-base and respiratory disorders.
Concept Summary
Concept
Key Takeaway
COPD Pathophysiology
Chronic airflow limitation, air trapping, and impaired CO2 elimination. Patients are often "CO2 retainers."
ABG in Uncompensated Respiratory Acidosis
pH < 7.35, PaCO2 > 45 mmHg, HCO3- normal.
Priority Nursing Intervention
Improve ventilation first (positioning, breathing techniques) before adjusting medications or oxygen.
Oxygen Therapy in COPD
Use low-flow oxygen (1-3 L/min NC). Target SpO2 88-92%. Avoid high flow to prevent suppressing the hypoxic drive.