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. This is not a compensatory mechanism for metabolic acidosis. In fact, during metabolic acidosis, the kidneys excrete hydrogen ions (acid) and reabsorb bicarbonate (base) to help normalize the pH of the blood.
B. Increased urinary output (polyuria) is not typically a direct compensatory response to metabolic acidosis. However, metabolic acidosis can lead to osmotic diuresis in certain conditions, which may increase urinary output as the body tries to excrete excess acids and maintain electrolyte balance.
C. Increased thirst (polydipsia) and hunger (polyphagia) are not typical compensatory responses to metabolic acidosis. These symptoms are more associated with hyperglycemia in diabetes rather than acid-base disturbances.
D. During metabolic acidosis, the respiratory system compensates by increasing the rate and depth of respirations (hyperventilation). By blowing off more CO2 (carbon dioxide), the body tries to decrease the

amount of carbonic acid in the blood, thereby increasing the pH towards normal. This compensatory mechanism helps to raise the pH back towards the normal range (7.35-7.45).

A. Give the client a back massage. B. Teach the client relaxation techniques. C. Assist the client to cough and deep breathe ev D. Encourage the client to turn every 4 hr. E. Administer analgesics as needed.

Correct Answer is ["B","C","E"]

Explanation

A. A back massage (A) can be soothing and may help with circulation, but it's not typically a priority immediately postoperative.
B. Teaching relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation can help the client manage pain, reduce anxiety, and promote faster recovery. These techniques empower the client to actively participate in their comfort and recovery process.

C. Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) due to shallow breathing. Coughing and deep breathing exercises help to expand lung volume, clear secretions, and prevent respiratory complications. It's important to encourage and assist the client in performing these exercises regularly.
D. Encouraging the client to turn every 4 hours helps prevent pressure ulcers and promotes good circulation, but turning might be more frequent depending on the surgery and the client's condition.
E. Pain management is crucial for postoperative comfort and recovery. Administering analgesics as needed helps to control pain effectively, which is essential for the client to participate in activities such as deep breathing, coughing, and moving, thereby reducing the risk of complications.

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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 assesses a diabetic client who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.39, PaCO2 27 mm Hg, and HCO3 19 mEq/L. Which sign or symptom does the nurse identify as an example of the client's compensatory mechanisms?

Correct Answer is D

Explanation

A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?

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