A 14-year-old girl is admitted to the ER with a suspected overdose of an unknown drug. Arterial blood gasses (ABG) are drawn with the following results: pH 7.31, PO₂ 88, PCO₂ 59, HCO₃ 22. Identify the initial action to be taken by the nurse. A)Insert a large-gauge nasogastric tube for gastric lavage. B)Insert a Foley catheter and obtain a urine for drug screen. C)Use a manual ventilator (ambu-bag) to assist with ventilation. D)Attach the client to a cardiac monitor and watch for dysrhythmia.

Question

Quizplus · Accepted Answer

The ABG indicates the client is experiencing respiratory acidosis, with an elevated PaCO2 and decreased pH. Therefore, the initial action should be to assist with ventilation using a manual ventilator (ambu-bag). Ventilatory support can help improve oxygenation and reduce the PaCO2 levels, which can help to increase the pH. The other options may be appropriate at some point, but are not the initial action needed.

A 14-Year-Old Girl Is Admitted to the ER with a Suspected