A nurse is caring for a 48-year-old male client who has pneumonia on a medical-surgical unit.
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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Cyanosis is a late sign of hypoxemia and not the most common initial manifestation of ARDS. It indicates severe oxygen deprivation but doesn’t typically appear first.
Choice B rationale
Diaphoresis, or excessive sweating, can occur with many conditions causing distress, but it’s not specifically the most common presenting symptom of ARDS. It's more of a nonspecific symptom of stress.
Choice C rationale
Somnolence, or drowsiness, might occur in severe respiratory distress when oxygen levels drop significantly, but it’s not the primary or most common presenting manifestation of ARDS.
Choice D rationale
Dyspnea, or difficulty breathing, is the hallmark of ARDS and the most common presenting symptom. It occurs due to the acute onset of severe hypoxemia caused by the underlying pathophysiology of ARDS.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Acidosis is a key characteristic of diabetic ketoacidosis due to the accumulation of ketoacids in the body from fat metabolism.
Choice B rationale
Low blood sugar is not associated with diabetic ketoacidosis; it is characterized by hyperglycemia.
Choice C rationale
Ketosis occurs in DKA due to the breakdown of fats instead of glucose for energy, leading to an accumulation of ketones.
Choice D rationale
Fluid overload is not typical of diabetic ketoacidosis; dehydration is more common due to osmotic diuresis.
Choice E rationale
Hyperglycemia is a hallmark of diabetic ketoacidosis, resulting from the lack of insulin and the consequent high levels of glucose in the blood.
Choice F rationale
Alkalosis is not associated with diabetic ketoacidosis; the condition is defined by metabolic acidosis. .
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