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","D"]

Explanation

Rationale

A. This is generally a good practice for clients who may have difficulty ambulating to the bathroom due to their condition. It promotes safety and reduces the risk of falls, especially during episodes of dyspnea.

B. A supine position can increase venous return to the heart and exacerbate symptoms of heart failure by increasing preload. This can lead to increased pulmonary congestion and respiratory distress. Therefore, this observation requires immediate intervention.

C. Providing a low sodium diet aligns with managing heart failure by reducing fluid retention and workload on the heart. This observation does not require immediate intervention unless there are specific dietary restrictions or concerns.

D. In heart failure, fluid restriction is often necessary to prevent fluid overload and exacerbation of symptoms. Having a full pitcher of water accessible to the client could lead to excessive fluid intake, which is concerning and requires immediate intervention.

E. A saline lock allows access for intravenous medications or fluids if needed. Its presence does not necessarily indicate a need for immediate intervention unless it is not functioning properly or if there are signs of infection or infiltration.

A. Ask the parent to decrease the infant's intake of fruits for 24 hours. B. Instruct the parent to change the child's diaper more often. C. Encourage the parent to apply lotion with each diaper change. D. Tell the parent to cleanse with soap and water at each diaper change.

Correct Answer is B

Explanation

Rationale

A. Fruits can sometimes increase stool acidity or frequency in infants, potentially aggravating diaper rash. However, unless there is a clear association between fruit intake and exacerbation of symptoms, restricting fruits for 24 hours may not directly address the current rash. It's more important to focus on topical care and diaper hygiene.

B. Changing diapers frequently helps keep the skin dry and reduces exposure to irritants like urine and stool. This intervention is crucial as prolonged exposure to moisture can contribute to diaper rash development and exacerbation.

C. Applying a barrier cream or diaper rash ointment can protect the skin from moisture and irritants, providing a protective layer that promotes healing. This intervention helps soothe the skin and prevent further irritation.

D. Using soap and water at every diaper change can be harsh on the delicate skin of infants, especially if the soap is not pH-balanced or contains fragrances. Plain water or a gentle, pH-balanced cleanser is preferable to avoid further irritation.

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Naxlex Comprehensive Predictor Exams

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.

Correct Answer is ["B","D"]

Explanation

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Correct Answer is B

Explanation

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

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

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.