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.

Answer and Explanation

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.

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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.

A. Notify information services department of the situation. B. Print electronic medical record (EMR) from backup server. C. Wait for notification that the system has been rebooted. D. Identify information as late entry in the record.

Correct Answer is A

Explanation

Rationale

A. Informing the information services department allows them to be aware of the issue promptly. They can then investigate the cause of the system failure and initiate appropriate measures to restore the system. It's important to involve IT professionals who are responsible for maintaining and troubleshooting the computer system.

B. While having access to patient information is crucial, printing from a backup server might not be immediately feasible or necessary if the primary system is expected to be restored soon. The nurse should first notify IT services to resolve the issue. If access to patient records is urgently needed and cannot be delayed, then printing from a backup server could be considered after notifying IT services.

C Waiting passively without taking action may delay the resolution of the issue. It's important for the nurse to proactively notify the information services department so they can begin troubleshooting and rebooting the system if necessary.

D. Labeling information as a late entry should only be considered once the system is back online and accessible. It should be done according to facility policies and procedures regarding late entries in medical records. However, this should not be the first action because the primary concern is to restore the functionality of the computer documentation system.

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Naxlex Comprehensive Predictor Exams

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Correct Answer is C

Explanation

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

Correct Answer is A

Explanation

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

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