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 B

Explanation

A. It is particularly sensitive to deficiencies in clotting factors, but it does not measure the deficiencies themselves
B. The activated partial thromboplastin time (aPTT) test measures the effectiveness of the intrinsic and common pathways of the coagulation cascade.
C. There is no need to skip breakfast or alter diet for an aPTT test. It is not affected by food intake or fasting status.

D. While aPTT is used to monitor heparin therapy, it is not typically used to monitor warfarin (a vitamin K antagonist) therapy. Warfarin therapy is usually monitored using the prothrombin time (PT) and international normalized ratio (INR) tests.

A. Give the client aback 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 PRN analgesics as needed.

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

Explanation

A. Postoperative patients often experience muscle tension and discomfort due to lying in one position for an extended period. A gentle back massage can help relieve muscle stiffness, promote relaxation, and improve circulation. It is a non-invasive comfort measure that can enhance the client's overall well- being.
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 are beneficial postoperatively as they encourage relaxation and improve overall comfort.
C. Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) or pneumonia due to shallow breathing or inadequate lung expansion. Coughing and deep breathing exercises help to clear secretions, improve lung function, and prevent respiratory complications. It is typically recommended to perform these exercises every hour to maintain lung expansion and prevent complications.
D. Encouraging the client to turn every 2 hours (D), not every 4 hours, is essential to prevent pressure ulcers and promote circulation.
E. Postoperative pain management is essential for the client's comfort and recovery. Pain can interfere with the client's ability to cough, deep breathe, and move effectively, which may increase the risk of complications. Administering analgesics as needed helps to control pain, improve overall comfort, and promote participation in necessary activities such as coughing, deep breathing, and turning.

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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 teaching a client scheduled for an activated partial thromboplastin time (aPTT). Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

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 ["A","B","C","E"]

Explanation

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?

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially?

A nurse is reviewing a client's CBC findings and discovers that the client's platelet count is 9,000/mm3. The nurse should monitor the client for which of the following conditions?

A nurse is caring for a client who has heart failure and is receiving IV furosemide. The nurse should monitor the client for which of the following electrolyte imbalances?

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

A nurse is caring for a client who is well-hydrated and who demonstrates no evidence of anemia. Which of the following laboratory values gives the nurse an assessment of the adequacy of the client's protein uptake and synthesis?

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?