A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find?

A. Check the client's distal pulses in both legs:

Checking the client's distal pulses in both legs is crucial to ensure that there is adequate blood flow and no signs of arterial occlusion or complications from the catheterization. This is an important assessment to detect potential vascular complications, such as a hematoma or an arterial blockage.

B. Keep the client overnight:

Keeping the client overnight is not typically required for all cardiac catheterization procedures. The need for an overnight stay depends on the individual case and any complications or comorbidities. Routine catheterizations often allow for discharge on the same day with appropriate monitoring.

C. Keep the client on bed rest for 12 hr:

Keeping the client on bed rest for 12 hours is excessive. Typically, bed rest is required for 2 to 6 hours following the procedure to allow the puncture site to stabilize and reduce the risk of bleeding. The exact duration of bed rest depends on the approach used and the patient's condition.

D. Restrict the client's oral fluids:

Restricting the client's oral fluids is generally not appropriate. In fact, increasing fluid intake is often encouraged to help flush out the contrast dye used during the procedure and to prevent renal complications. Monitoring for fluid balance is important, but outright restriction is not typically indicated unless there is a specific medical reason.

(A) Place the client in high-Fowler’s position and encourage the use of incentive spirometer and coughing: This is the most appropriate action. The high-Fowler’s position can help improve lung expansion and gas exchange, while the use of an incentive spirometer and coughing can help clear secretions and improve ventilation. This is particularly important for a client who is postoperative following an open thoracotomy.

(B) Switch oxygen to a nonrebreather mask: Switching to a nonrebreather mask may deliver a higher concentration of oxygen, but it does not address the underlying issue of impaired gas exchange due to decreased lung expansion and retained secretions.

(C) Position the client prone and have the respiratory therapist perform postural drainage: While postural drainage can help clear secretions, it may not be comfortable or safe for a client who is 1 day postoperative following an open thoracotomy.

(D) Increase oxygen to 70%: Increasing the oxygen concentration may improve the client’s oxygen saturation, but it does not address the underlying issue of impaired gas exchange due to decreased lung expansion and retained secretions. Furthermore, excessively high concentrations of oxygen can have harmful effects, such as oxygen toxicity or suppression of the respiratory drive in some clients.