A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 88 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)]

Increase ventilator tidal volume.

Decrease expiratory flow time.

Decrease expiratory pressure.

Increase rate of ventilation.

Answer and Explanation

The Correct Answer is D

A. Increasing the ventilator tidal volume could improve the client's ventilation but may not adequately address the severe hypercapnia indicated by the elevated PaCO2.

B. Decreasing expiratory flow time is not a priority and may not improve ventilation effectively.

C. Decreasing expiratory pressure does not directly address the underlying problem of carbon dioxide retention.

D. Increasing the rate of ventilation is the most appropriate intervention to improve carbon dioxide elimination and correct the acid-base imbalance indicated by the low pH and high PaCO2.

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Correct Answer is A

Explanation

A. Fluid resuscitation due to capillary leaking is the primary goal when administering crystalloid fluids after burns. Severe burns lead to increased capillary permeability, causing fluid to leak into the interstitial space and necessitating resuscitation to restore intravascular volume.

B. While extension of plasma volume is a consideration, the primary focus in burn management is addressing fluid resuscitation to compensate for fluid loss from capillary leakage rather than simply waiting for blood products.

C. Replacement of insensible water loss occurs, but it is not the main physiological response targeted with crystalloid fluid administration in the acute phase after significant burns.

D. Restoration of electrolyte balance is important, but the immediate concern following a burn is fluid resuscitation to maintain adequate circulation and prevent shock.

A. Tomato juice and gluten free crackers. B. Dill pickles and black olives. C. Plain baked sweet potato. D. Canned chicken broth with barley.

Correct Answer is C

Explanation

A. Tomato juice may contain high sodium levels, which is not ideal for a hypertensive diet.

B. Dill pickles and black olives are typically high in sodium, which can exacerbate hypertension.

C. A plain baked sweet potato is low in sodium and high in potassium, making it a suitable choice for someone with hypertension.

D. Canned chicken broth often contains high levels of sodium, which is not recommended for hypertension management.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

Correct Answer is C

Explanation

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