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 C

Explanation

A. A hematocrit of 40% is within the normal range for females, which is typically around 37-47%. This result is not concerning and does not typically require immediate notification to the surgeon.
B. A creatinine level of 0.9 mg/dL is within the normal range for adults (normal range varies slightly among laboratories but is generally around 0.5-1.1 mg/dL). This result indicates normal kidney function and does not require immediate notification.
C. A white blood cell (WBC) count of 20,000/mm3 is elevated above the normal range, which is typically between 4,500-11,000/mm3. An elevated WBC count could indicate infection or inflammation. Given the client is preoperative, an elevated WBC count may suggest an underlying infection that needs to be addressed before proceeding with surgery. The nurse should notify the surgeon promptly so appropriate evaluation and management can be initiated.
D. A potassium level of 3.8 mEq/L is within the normal range (normal range is generally 3.5-5.0 mEq/L). This result is not concerning and does not require immediate notification to the surgeon.

A. Use IV tubing specific for heparin sodium when administering the infusion. B. Administer 50,000 units of heparin by IV bolus every 12 hr. C. Have vitamin K available on the nursing unit. D. Check the activated partial thromboplastin time (aPTT) every 4 hr.

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.

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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

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