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 B

Explanation

Rationale

A. Measuring vital signs, including respiratory rate, heart rate, blood pressure, and oxygen saturation, is important to assess the client's overall status and to determine the severity of the dyspnea. Vital signs provide essential information to guide further interventions. While important, this action may not directly alleviate the client's immediate distress from dyspnea.

B. Placing the client in a high Fowler's position (sitting upright with the head of the bed elevated to 90 degrees) helps to maximize chest expansion and improve lung ventilation. This position can relieve dyspnea by reducing pressure on the diaphragm and improving lung compliance. It is a simple and effective intervention for clients experiencing respiratory distress.

C. While deep breathing exercises are beneficial for promoting lung expansion and improving respiratory function, they may not be appropriate as the first action when the client is already dyspneic. The priority

should be to position the client to alleviate immediate breathing difficulty before initiating exercises that require active participation.

D. Auscultating breath sounds is important for assessing lung function and detecting any abnormalities such as adventitious sounds (e.g., crackles, wheezes). However, this action is secondary to placing the client in a high Fowler's position to relieve dyspnea. Auscultation can be performed after the client's breathing has stabilized.

Correct Answer is []

Explanation

Potential condition: Polycythemia

Actions to take

Have the parents increase the child's caloric intake: Polycythemia in children with tetralogy of Fallot can be managed by ensuring adequate hydration and nutrition. Increasing caloric intake helps support growth and development and can prevent excessive erythrocytosis.

Take the child's vital signs: Regular monitoring of vital signs, including heart rate, respiratory rate, blood pressure, and temperature, is essential to assess the child's cardiovascular status and response to treatment.

Parameters to monitor

Oxygen saturation: Monitoring oxygen saturation helps assess the adequacy of pulmonary blood flow and oxygenation in a child with tetralogy of Fallot and polycythemia.

Weight: Monitoring weight is crucial to assess growth and nutritional status. Children with tetralogy of Fallot may have poor weight gain due to increased metabolic demands and potential feeding difficulties.

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Naxlex Comprehensive Predictor Exams

The nurse observes that a client with ascites is dyspneic. Which action should the nurse implement first?

Correct Answer is B

Explanation

Correct Answer is []

Explanation

Actions to take

Parameters to monitor

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