A nurse is caring for an adult client who has pneumonia on the medical-surgical unit. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation & Rationale
Final Bowtie Mapping Condition: Respiratory acidosis Actions: Prepare the client for intubation; Administer bronchodilator Parameters: Correct placement of ETT; Repeat ABGs Most Likely Condition Respiratory acidosis Rationale: ABGs show pH 7.25 (acidic), PaCO₂ 62 mm Hg (elevated), HCO₃⁻ 22 mEq/L (normal). This indicates uncompensated respiratory acidosis due to hypoventilation and CO₂ retention. The client’s shallow, rapid respirations and poor oxygenation despite supplemental O₂ confirm worsening respiratory failure. ✅ Actions to Take Prepare the client for intubation Rationale: The client is tiring, hypoxemic, and retaining CO₂ despite high-flow oxygen. Mechanical ventilation is needed. Administer bronchodilator Rationale: Helps relieve airway obstruction, improve ventilation, and reduce CO₂ retention. 📊 Parameters to Monitor Correct placement of the endotracheal tube (ETT) Rationale: Ensures effective ventilation and oxygenation once intubated. Repeat arterial blood gas labs Rationale: Tracks improvement or worsening of acid-base balance and ventilation status.