A client has been placed on Contact Precautions. The client’s family is very afraid to visit. What is the best action for the nurse to take?

Choice A rationale:
Uncompensated Respiratory Acidosis is characterized by a low pH (less than 7.35) and a high pCO2 (greater than 45 mmHg). In this case, the pH is slightly elevated (7.46), making this option less likely.
While the pCO2 is elevated (46 mmHg), the body has begun to compensate, as evidenced by the elevated HCO3 (29 mEq/L). This partial compensation does not align with an uncompensated respiratory acidosis.
Choice B rationale:
Compensated Metabolic Acidosis would present with a normal pH (7.35-7.45) due to full compensation by the respiratory system. In this case, the pH is slightly elevated (7.46), which is not consistent with full compensation.
Additionally, the HCO3 is elevated (29 mEq/L), which is characteristic of metabolic alkalosis, not acidosis.
Choice C rationale:
Partially Compensated Metabolic Alkalosis is the most likely interpretation based on the ABG results. The pH is elevated (7.46), indicating alkalosis.
The HCO3 is also elevated (29 mEq/L), which is the primary cause of metabolic alkalosis.
The pCO2 is elevated (46 mmHg), which is a compensatory mechanism to try to normalize the pH. However, the compensation is not complete, as the pH is still slightly elevated.
This partial compensation is consistent with partially compensated metabolic alkalosis.
Choice D rationale:
Partially Compensated Respiratory Acidosis would present with a low pH (less than 7.35) and an elevated pCO2 (greater than 45 mmHg).
The HCO3 would also be elevated, but to a lesser degree than in metabolic alkalosis, as it's a secondary compensatory mechanism.
In this case, the pH is slightly elevated (7.46), making respiratory acidosis less likely.

Rationale for Choice A:
Documenting and continuing to monitor is a crucial aspect of nursing care; however, in this scenario, it would not be the first action to take. The significant drop in blood pressure warrants immediate intervention to prevent potential complications.
While monitoring is essential, it does not actively address the underlying cause of the hypotension. Relying solely on monitoring could delay necessary interventions and potentially compromise patient safety.
It's important to balance monitoring with timely interventions to ensure optimal patient outcomes. In this case, calling for assistance takes priority over documentation and continued monitoring.
Rationale for Choice B:
Repeating the blood pressure in 15 minutes could delay critical interventions if the hypotension is severe. Timely action is crucial to maintain adequate tissue perfusion and prevent organ damage.
Waiting to recheck the blood pressure could potentially worsen the patient's condition and lead to adverse outcomes. It's essential to act promptly when a significant change in vital signs occurs.
Rationale for Choice D:
While notifying the primary healthcare provider is an important step, it may not be the most immediate action in this situation. The Rapid Response Team is specifically trained to handle acute patient deterioration and can provide timely interventions.
The Rapid Response Team can initiate life-saving measures, such as administering fluids or medications, while the primary healthcare provider is being notified. This ensures that the patient receives prompt and appropriate care.
Rationale for Choice C:
Calling the Rapid Response Team is the most appropriate first action in this scenario because it ensures a rapid and coordinated response to the patient's hypotension.
The Rapid Response Team can quickly assess the patient, initiate interventions, and potentially prevent further complications. They can also facilitate communication and collaboration among healthcare providers.
Early activation of the Rapid Response Team has been shown to improve patient outcomes in various clinical settings, including postoperative care.