A nurse is reviewing the ABG results for a client. The client's results are pH 7.47, PaCO2 30 mm Hg, HCO3 25 mEq/L, and SaO2 90%. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

The correct answer is choice d. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Choice A rationale:

Inserting the tip of the enema tube 8 cm (3.1 in) is within the recommended range for adults, which is typically 7.5 to 10 cm (3 to 4 in). This action does not require intervention.

Choice B rationale:

Elevating the head of the bed when caring for a client’s body after death is a standard practice to prevent discoloration of the face and to facilitate drainage. This action does not require intervention.

Choice C rationale:

Using a clean washcloth, soap, and water for indwelling catheter care is appropriate and follows infection control guidelines. This action does not require intervention.

Choice D rationale:

Using scissors to remove the tape that secures a peripheral IV catheter is unsafe as it poses a risk of cutting the catheter or the client’s skin. This action requires intervention to ensure the nurse uses a safer method, such as using adhesive remover or gently peeling the tape away by hand.

Choice A rationale:

Performing oral care once each day is not sufficient to reduce the risk of ventilator-associated pneumonia (VAP). Ventilated patients are at an increased risk of developing VAP due to the presence of an endotracheal tube that bypasses the body's natural defenses. Bacteria can accumulate in the mouth and respiratory tract, leading to pneumonia. Therefore, performing oral care only once a day is inadequate for maintaining oral hygiene and preventing VAP.

Choice B rationale:

Brushing the client's teeth with a firm-bristle toothbrush can cause trauma to the oral tissues, potentially leading to bleeding and irritation. In critically ill patients with an endotracheal tube, using a firm-bristle toothbrush can exacerbate the risk of infection and VAP. It is essential to use gentle and non-traumatic methods for oral care to maintain the integrity of the oral mucosa.

Choice C rationale:

Swabbing the client's mouth with chlorhexidine solution is the correct choice. Chlorhexidine is an antiseptic solution that effectively reduces the growth of bacteria in the oral cavity. Regular use of chlorhexidine mouthwash has been shown to decrease the risk of VAP in mechanically ventilated patients. By reducing the bacterial load in the mouth, the risk of aspiration and subsequent pneumonia is lowered, making it a crucial intervention for preventing VAP.

Choice D rationale:

Raising the head of the bed by 15° for oral care is an important measure to prevent aspiration during oral care. However, it alone is not sufficient to reduce the risk of VAP. While proper head positioning helps prevent the entry of oral secretions into the lower respiratory tract, it must be combined with effective oral hygiene practices, such as using chlorhexidine solution, to comprehensively reduce the risk of VAP.