A nurse is reviewing the ABG values of a client who has pneumonia. Which of the following findings indicates the client is developing respiratory acidosis?

PaO2 85 mmHg

pH 7.47

HCO3 25 mEq/L

PaCO2 55 mmHg

Answer and Explanation

The Correct Answer is D

Choice A reason: PaO2 85 mmHg is within the normal range of 80 to 100 mmHg and does not indicate any hypoxemia or oxygen deficiency.

Choice B reason: pH 7.47 is within the normal range of 7.35 to 7.45 and does not indicate any acid-base imbalance.

Choice C reason: HCO3 25 mEq/L is within the normal range of 22 to 26 mEq/L and does not indicate any metabolic disturbance.

Choice D reason: PaCO2 55 mmHg is above the normal range of 35 to 45 mmHg and indicates respiratory acidosis, which is a condition where the lungs cannot eliminate enough carbon dioxide and the blood becomes too acidic. This can be caused by pneumonia, which can impair gas exchange and ventilation.

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Correct Answer is B

Explanation

Choice A reason: Delaying ambulation until the next day is not an appropriate intervention, as it can cause stiffness, muscle weakness, or joint contractures in the affected knee. The nurse should encourage regular exercise and activity within the client's tolerance level to maintain joint mobility and function.

Choice B reason: Applying moist heat prior to ambulation is an appropriate intervention, as it can reduce pain and inflammation in the affected knee by increasing blood flow and relaxing the muscles and tendons around the joint.

Choice C reason: Using a continuous passive motion machine is not an appropriate intervention for osteoarthritis, as it is mainly used after knee replacement surgery to prevent scar tissue formation and improve range of motion in the new joint.

Choice D reason: Restricting intake of dairy products is not an appropriate intervention for osteoarthritis, as dairy products are good sources of calcium and vitamin D that can support bone health and prevent osteoporosis. The nurse should advise the client to eat a balanced diet that includes fruits, vegetables, whole grains, lean protein, and low-fat dairy products.

A. Wear an N95 mask when in the client's room. B. Wear a gown when caring for the client. C. Wear a simple face mask when caring for the client. D. Place the client in a negative air pressure room.

Correct Answer is A

Explanation

Choice A reason: Wearing an N95 mask when in the client's room is an appropriate instruction, as it can protect the AP from inhaling airborne droplets that contain pertussis bacteria, which can cause a highly contagious respiratory infection.

Choice B reason: Wearing a gown when caring for the client is not necessary, as pertussis is not transmitted by contact with body fluids or surfaces.

Choice C reason: Wearing a simple face mask when caring for the client is not sufficient, as it does not filter out small particles that can carry pertussis bacteria and enter the respiratory tract.

Choice D reason: Placing the client in a negative air pressure room is not indicated, as pertussis is not classified as an airborne infection that requires isolation in a specially ventilated room.

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A nurse is reviewing the ABG values of a client who has pneumonia. Which of the following findings indicates the client is developing respiratory acidosis?

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Naxlex Comprehensive Predictor Exams

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