A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement?Reference Range:
Arterial Blood Gas (ABG)
pH [Adult/child: 7.35 to 7.45]
PaCO2 [Adult/child: 35 to 45 mm Hg)
HCO- [Adult/child: 21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [Adult/child: 80 to 100 mm Hg)
Increase rate of ventilation.
Decrease expiratory flow time.
Increase ventilator tidal volume.
Decrease expiratory pressure.
The Correct Answer is A
Rationale
A. The client's pH is low (acidotic), and the PaCO2 is high (respiratory acidosis). Increasing the rate of ventilation (respiratory rate) can help to decrease PaCO2 by increasing alveolar ventilation, thereby helping to correct respiratory acidosis.
B. Expiratory flow time affects the time available for exhalation. While this may affect the overall mechanics of ventilation, it is not directly targeting the primary issue of elevated PaCO2 and acidosis.
C. Increasing tidal volume increases the volume of air delivered with each breath. This can improve ventilation efficiency but may not address the underlying problem of elevated PaCO2 unless it leads to increased minute ventilation.
D. Expiratory pressure is related to positive end-expiratory pressure (PEEP), which helps maintain alveolar recruitment and improve oxygenation. Decreasing expiratory pressure may not directly address the elevated PaCO2 and acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. While it is important background information, it is not directly relevant to the acute change in the client's condition (increasing confusion and agitation). Therefore, this should not be provided first in the SBAR communication.
B. Knowing the client's current medications is important for understanding any potential causes or exacerbating factors related to the sudden onset of confusion and agitation. However, this is also background information and does not immediately address the acute change in the client's condition.
C. This is the most critical piece of information to provide first in the SBAR communication. Sudden onset of increasing confusion and agitation can indicate various urgent issues such as delirium, infection, metabolic disturbances, or neurological complications. This requires immediate attention and intervention from the healthcare provider.
D. While knowing the client's healthcare power of attorney is important for ensuring appropriate decision-making if needed, it is not urgent information in the context of reporting a sudden change in the client's condition. This can be discussed later in the SBAR communication or as part of the background information if relevant to the client's care.
Correct Answer is C
Explanation
Rationale
A. This option may seem reasonable, as dehydration and electrolyte imbalances are concerns in DKA. However, simply drinking electrolyte fluids without addressing the underlying cause of DKA (which is insulin deficiency) would not effectively manage the condition.
B. Physical activity may exacerbate DKA if insulin levels are inadequate. It is important to stabilize blood glucose levels and manage DKA before engaging in physical activity.
C. In DKA, there is an absolute or relative deficiency of insulin, leading to hyperglycemia and ketosis. Regular insulin helps to lower blood glucose levels and inhibit further breakdown of fats into ketones, thereby correcting the metabolic imbalance associated with DKA.
D. Monitoring urine output is important in assessing hydration status, but it does not address the immediate need to manage DKA. This action alone would not correct the underlying cause of increased thirst in DKA.
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