A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.1, PaCO2 70 mm Hg, and HCO3 22 mEq/L. Which intervention does the nurse implement first?

Assess the airway.

Administer prescribed bronchodilators.

Administer prescribed mucolytics.

Provide oxygen.

Answer and Explanation

The Correct Answer is A

A.   Assessing the airway is always a priority in any client care situation, especially when there are respiratory abnormalities such as respiratory acidosis. Ensuring a patent airway is crucial to maintain adequate oxygenation and ventilation.
B.   Bronchodilators are typically used to treat conditions such as bronchoconstriction in asthma or chronic obstructive pulmonary disease (COPD). However, in the context of respiratory acidosis with an elevated PaCO2, the primary issue is not bronchoconstriction but rather impaired gas exchange due to inadequate ventilation.
C.   Mucolytics are medications used to thin mucus and facilitate its removal from the respiratory tract. While they can be beneficial in conditions with thick secretions, they do not address the underlying cause of respiratory acidosis, which is inadequate CO2 elimination.
D.   Providing oxygen can help improve oxygenation in clients with respiratory acidosis. However, it is important to note that oxygen alone will not correct the underlying cause of respiratory acidosis (elevated PaCO2). Oxygen therapy is supportive and helps to improve oxygen delivery to tissues while other interventions are addressed.

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Correct Answer is D

Explanation

A. Heparin should be administered using IV tubing that is specifically labeled for heparin or that has been dedicated for anticoagulant use only. However, this is not the most important action.

B. Heparin is not typically administered as a bolus (large single dose) because of its rapid onset of action and potential for causing bleeding complications. Instead, heparin is usually administered as a continuous IV infusion to achieve and maintain therapeutic anticoagulation.
C. While vitamin K is an antidote for reversing the effects of warfarin (a different type of anticoagulant), it is not used for reversing the effects of heparin. The reversal agent for heparin is protamine sulfate. Therefore, having vitamin K available is not necessary for managing a client receiving heparin.
D. The aPTT is a laboratory test used to monitor the therapeutic effect of heparin therapy. It measures the clotting time of blood and helps ensure that the client's heparin infusion is within the desired therapeutic range. Checking aPTT regularly (usually every 4-6 hours initially, then adjusting based on results) is essential to maintain therapeutic anticoagulation and avoid complications like bleeding or clotting.

A. "I cook my food with canola oil." B. "I eat two eggs for breakfast each morning C. "I flavor my meat with lemon juice." D. "I take an omega-3 supplement daily."

Correct Answer is B

Explanation

A. Canola oil is a healthier option compared to oils high in saturated fats, such as butter or lard. It does not significantly contribute to dietary cholesterol intake. Therefore, this statement does not indicate a need for follow-up teaching on a low-cholesterol diet.
B. Eggs are high in dietary cholesterol, and consuming two eggs daily can significantly increase cholesterol intake. For someone with elevated cholesterol levels or a history of atherosclerosis, this dietary habit may contribute to further elevation of cholesterol levels and potentially worsen cardiovascular health. Hence, this statement indicates the need for follow-up teaching on reducing dietary cholesterol intake.
C. Lemon juice is a low-calorie and low-cholesterol flavoring option. It does not significantly impact cholesterol intake. Therefore, this statement does not indicate a need for follow-up teaching on a low- cholesterol diet.
D. Omega-3 fatty acids are beneficial for heart health and do not contribute to dietary cholesterol intake. In fact, they may help reduce triglyceride levels and inflammation. Therefore, this statement does not indicate a need for follow-up teaching on a low-cholesterol diet.

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A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.1, PaCO2 70 mm Hg, and HCO3 22 mEq/L. Which intervention does the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow-up teaching on a low-cholesterol diet?

Correct Answer is B

Explanation

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