hard · NCLEX-RN risk-reduction

The nurse assesses the client at 05:15 and notes severe hypotension, worsening tachycardia, and profound hypoxemia. Which nursing action is the safest and most urgent first response? Apply the response specifically to this case: mechanically ventilated COPD client with serial ABGs showing acute-on-chronic respiratory acidosis and changing compensation after ventilator adjustments.

1. Disconnect the endotracheal tube from the ventilator circuit and allow the chest to decompress.
2. Increase the ventilator positive end-expiratory pressure (PEEP) to 15 cmH2O to match the measured auto-PEEP.
3. Increase the FiO2 to 100% and initiate a rapid 1,000 mL normal saline fluid bolus via a wide-open peripheral line.
4. Perform immediate needle decompression of the left pleural space using a large-bore angiocatheter.

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