A nurse is caring for a 48-year-old male client who has pneumonia on a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

The client has respiratory acidosis as indicated by a pH of 7.25 (normal: 7.35-7.45) and elevated pCO2 of 62 mm Hg (normal: 35-45 mm Hg). This condition occurs when the lungs cannot remove enough CO2, leading to its buildup and lowering the blood pH. Immediate interventions like intubation can help manage airway and ventilation. Starting an IV drip of 0.9% sodium chloride can help address dehydration, supporting hemodynamic stability. Monitoring the correct placement of the endotracheal tube ensures effective ventilation. Regular arterial blood gases assessment helps evaluate the effectiveness of interventions and the client's respiratory status.

Prepare the client for intubation: Intubation is essential to secure the airway and provide mechanical ventilation, addressing hypoxia and hypercapnia by improving gas exchange.

Start a 0.9% sodium chloride IV drip: This fluid helps in correcting dehydration, supporting blood pressure, and improving renal perfusion, which is critical in managing acid-base balance.

Correct placement of endotracheal tube: Ensuring the tube is in the correct position guarantees effective ventilation and prevents complications such as aspiration or pneumothorax.

Arterial blood gases: Regular ABG assessments help monitor the effectiveness of ventilation and guide adjustments in therapy, ensuring the client’s acid-base balance is maintained.

Metabolic acidosis is not correct as the primary issue here is a respiratory one, indicated by elevated pCO2 and lower pH.

Respiratory alkalosis is incorrect as it would present with a high pH and low pCO2, unlike the client's findings.

Metabolic alkalosis is ruled out because it would show elevated pH and bicarbonate levels, which is not seen in the client's ABG results.

Nursing Test Bank

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Free Nursing Study Resources

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

Explanation

Choice A rationale:

Obtaining a wound culture is crucial to identify the causative organism and guide appropriate antibiotic therapy. Prompt identification and treatment of the infection source can prevent further systemic complications.

Choice B rationale:

Rapidly administering 30 mL/kg of normal saline helps to restore intravascular volume, improve hemodynamic stability, and enhance tissue perfusion. This intervention is vital in the initial management of sepsis to prevent organ dysfunction.

Choice D rationale:

Obtaining blood cultures before initiating antibiotic therapy is essential to identify the causative microorganism and tailor antibiotic treatment. This step ensures accurate diagnosis and effective management of sepsis.

Choice E rationale:

Administering broad-spectrum antibiotics as soon as possible is critical in managing sepsis. Early and appropriate antibiotic therapy significantly reduces mortality and morbidity by targeting the suspected pathogens promptly.

A. Agitation. B. Dysphagia. C. Nausea. D. Hypotension.

Correct Answer is A

Explanation

Choice A rationale

Agitation is a common manifestation of hypoxemia due to insufficient oxygen reaching the brain and other vital organs.

Choice B rationale

Dysphagia, or difficulty swallowing, is not a typical manifestation of hypoxemia during an asthma attack.

Choice C rationale

Nausea can occur but is not a primary indicator of hypoxemia.

Choice D rationale

Hypotension may occur with severe hypoxemia but is not a direct manifestation of asthma-related hypoxemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 73-year-old male client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.

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

Explanation

A nurse is assessing a client for hypoxemia during an asthma attack.Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

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A nurse is preparing discharge instructions for a client who has cirrhosis of the liver.Which of the following statements should be included in the education materials?

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

A nurse is caring for a client who has Cushing's syndrome.The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply)

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A nurse is caring for a client who has pleural effusion and has undergone thoracentesis.The nurse should identify which of the following findings as indicative of an infection?

A nurse is providing care for a client diagnosed with diabetic ketoacidosis (DK

A nurse is providing education to a client who is suspected of having type 1 diabetes mellitus.Which of the following statements would the nurse include in client education?