A nurse is reviewing the arterial blood gas values for a client. The nurse should recognize that the values indicate which of the following acid-base imbalances?

The values are:

• pH: 7.56
• PaCO2: 55 mmHg
• HCO3: 33 mEq/L

Normal ranges:

• pH: 7.35-7.45
• PaCO2: 35-45 mmHg
• HCO3: 22-28 mEq/L

Choice A Reason:

Securing the oxygen tubing to the bed sheet near the client’s head is not recommended because it can lead to accidental dislodgement of the tubing, which can interrupt the oxygen supply. Additionally, this practice does not address the potential for nasal dryness and irritation that can occur with oxygen therapy. Properly securing the tubing should involve ensuring it is comfortably positioned and not at risk of being pulled or dislodged.

Choice B Reason:

Attaching a humidifier bottle to the base of the flow meter is the correct action because it helps to add moisture to the oxygen being delivered to the client. Oxygen therapy, especially at higher flow rates like 5 L/min, can dry out the nasal passages and mucous membranes, leading to discomfort and potential complications. The humidifier bottle ensures that the oxygen is humidified, which helps to prevent dryness and irritation, making the therapy more comfortable and effective for the client.

Choice C Reason:

Applying petroleum jelly to the nares is not recommended because petroleum-based products can be flammable and pose a risk when used in conjunction with oxygen therapy. Additionally, petroleum jelly can trap bacteria and potentially lead to infections. Instead, water-based lubricants or saline nasal sprays are safer alternatives for soothing dry nasal passages.

Choice D Reason:

Removing the nasal cannula while the client eats is not advisable because it interrupts the continuous delivery of oxygen, which is essential for clients with pneumonia who may already have compromised respiratory function. Instead, the nurse should ensure that the nasal cannula is securely in place and that the client is receiving the prescribed oxygen therapy at all times, including during meals.

Choice A reason: To provide a means for medication administration

A Jackson-Pratt (JP) drain is not used for medication administration. Its primary function is to remove fluids that accumulate in a surgical site, which helps to prevent infection and promote healing. Medication administration is typically done through other means such as intravenous (IV) lines or oral medications.

Choice B reason: To eliminate the need for wound dressings

The JP drain does not eliminate the need for wound dressings. Dressings are still required to protect the wound site, absorb any additional drainage, and prevent infection. The JP drain works in conjunction with dressings to manage wound care effectively.

Choice C reason: To limit the amount of bleeding from the surgical site

While the JP drain can help manage bleeding by removing accumulated blood, its primary purpose is not to limit bleeding. Instead, it is designed to prevent the buildup of fluids, including blood, which can lead to complications such as hematomas or infections.

Choice D reason: To prevent fluid from accumulating in the wound

The primary purpose of a Jackson-Pratt (JP) drain is to prevent fluid from accumulating in the wound. This includes blood, lymphatic fluid, and other bodily fluids that can collect at the surgical site. By removing these fluids, the JP drain helps to reduce the risk of infection, promote healing, and decrease the likelihood of complications.