A client is admitted with a suspected opioid overdose and a respiratory rate of 6 breaths per minute. Which of the following data would the nurse anticipate? (SELECT ALL THAT APPLY)
pH 7.29
Pa CO2 54
pH 7.51
PaO2 72
Pa CO2 31
Correct Answer : A,B
A. pH 7.29: A respiratory rate of 6 breaths per minute suggests hypoventilation, which can lead to respiratory acidosis due to retention of carbon dioxide (CO2). A decrease in pH (acidosis) is expected in this scenario.
B. PaCO2 54: In respiratory acidosis, PaCO2 levels are elevated due to inadequate ventilation, leading to CO2 retention. Therefore, an elevated PaCO2 level would be anticipated in this situation.
C. pH 7.51: A pH of 7.51 indicates alkalosis, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
D. PaO2 72: Oxygenation may be impaired in opioid overdose due to respiratory depression, but this PaO2 level is within the normal range. Hypoxemia is not typically a prominent feature of respiratory acidosis unless there are concurrent respiratory conditions or complications. Therefore, this choice is not anticipated.
E. PaCO2 31: A PaCO2 level of 31 indicates hypocapnia, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Assessing family members for potential poor bereavement outcomes, such as complicated grief or unresolved issues, allows the nurse to provide appropriate support and interventions. This may involve identifying risk factors, offering counseling or referrals to support services, and providing emotional support to family members as needed.
C. Assessing the understanding of the dying process among family members helps the nurse identify their informational needs, address misconceptions, and provide education and support accordingly. Clear communication and open dialogue can help alleviate anxiety and uncertainty and empower family members to participate actively in the care of their loved one.
E. Respecting and supporting the client's religious and cultural beliefs and practices is essential in providing culturally competent care. This may involve collaborating with spiritual or religious leaders, facilitating rituals or ceremonies, providing appropriate accommodations, and honoring the client's preferences regarding end-of-life care and decision-making.
B. Encouraging frequent meals may not be appropriate during the dying process, as the client's appetite and ability to eat may be significantly diminished. Instead, the focus should be on providing comfort measures, maintaining oral hygiene, and offering small, manageable amounts of food or fluids based on the client's preferences and comfort level.
D. Urging the family to limit their time with the client is contrary to supporting them during the dying process. Family presence and involvement are essential for providing emotional support, companionship, and comfort to the client. Encouraging meaningful interactions and opportunities for sharing memories and expressions of love can promote a sense of connection and closure for both the client and their family.
Correct Answer is C
Explanation
C. Excessive noise in the hospital environment, including alarms, conversations, and equipment noises, can disrupt sleep and negatively impact sleep quality. Therefore, limiting unnecessary noise on the unit is a crucial nursing intervention for improving sleep quality in the acute care setting. This may involve implementing quiet hours, reducing unnecessary conversations and activities during nighttime hours, and using noise-reducing strategies such as earplugs or white noise machines.
A. While providing a bedtime snack may help alleviate hunger and promote comfort, especially if the client is on a restricted diet or experiencing appetite changes, it may not directly address factors affecting sleep quality. Additionally, consuming food close to bedtime may not be suitable for all patients, especially those with dietary restrictions or certain medical conditions. Therefore, while a bedtime snack may be beneficial in some cases, it may not be the most important intervention for improving sleep quality in the acute care setting.
B. Pulling curtains around the bed can help create a sense of privacy and reduce visual distractions, which may contribute to a more conducive sleep environment. Enhanced privacy can also promote relaxation and feelings of security, potentially improving sleep quality. However, while privacy curtains can mitigate some external disturbances, they may not completely eliminate factors that affect sleep, such as noise or light.
D. Providing a backrub can promote relaxation, relieve tension, and enhance comfort, which may contribute to improved sleep quality for some patients. Massage therapy has been shown to reduce stress and promote relaxation, potentially facilitating better sleep. However, while backrubs can be a beneficial adjunct to promoting relaxation and comfort, they may not address all factors that affect sleep quality in the acute care setting.
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