A nurse is reviewing the ABGs of a client who has pneumonia. The nurse should identify which of the following findings is an indication of respiratory acidosis.

Choice A rationale:

Administering morphine intermittent IV bolus every 2 hours is not a suitable intervention for reducing the risk of atelectasis. While pain management is important postoperatively, morphine can depress respiratory function and increase the risk of atelectasis.

Choice B rationale:

Turning the client from side to side every 4 hours is important for preventing pressure ulcers and promoting comfort, but it is not a specific intervention for reducing the risk of atelectasis.

Choice C rationale:

Providing nasotracheal suctioning for 15 to 20 seconds at a time is not a preventive measure for atelectasis. Suctioning may be necessary for airway clearance in certain situations, but it does not address the root cause of atelectasis.

Choice D rationale:

This is the correct choice. Instructing the client to hold the inhaled breath for 2 to 5 seconds with incentive spirometer use is an effective intervention to reduce the risk of atelectasis. Incentive spirometry helps to expand the lungs and improve ventilation, preventing atelectasis after surgery.

Answer: A

Rationale:

A) Place the client in a room with negative airflow: Disseminated herpes zoster (shingles) requires airborne precautions because the virus can become aerosolized. A room with negative airflow helps prevent the spread of the virus to other areas, protecting healthcare workers and other patients from infection.

B) Remove isolation gown after leaving the client's room: Isolation gowns should be removed before leaving the client's room to prevent the spread of contaminants to other areas. This intervention is important for infection control but is not specific to the requirement for negative airflow in cases of disseminated herpes zoster.

C) Apply ketoconazole to the lesions three times per day: Ketoconazole is an antifungal medication and is not used for treating herpes zoster, which is caused by a viral infection. Antiviral medications, such as acyclovir, are appropriate for treating herpes zoster lesions.

D) Provide the client with eye protection for ultraviolet B light therapy: Eye protection is necessary during UVB light therapy to protect the eyes, but UVB light therapy is not a standard treatment for disseminated herpes zoster. The priority intervention is to prevent the spread of the infection by using a negative airflow room.