A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

Choice A Reason:

Respiratory acidosis is characterized by a low pH (below 7.35) and an elevated PaCO₂ (above 45 mm Hg). This condition occurs when there is an accumulation of carbon dioxide in the blood due to hypoventilation or impaired lung function. In this case, the client’s pH is elevated, and PaCO₂ is low, which does not align with respiratory acidosis.

Choice B Reason:

Respiratory alkalosis is indicated by a high pH (above 7.45) and a low PaCO₂ (below 35 mm Hg). This condition results from hyperventilation, which causes excessive exhalation of carbon dioxide. The client’s ABG results show a pH of 7.50 and a PaCO₂ of 29 mm Hg, consistent with respiratory alkalosis.

Choice C Reason:

Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO₃ (below 21 mEq/L). This condition occurs due to an accumulation of acids or a loss of bicarbonate in the body. The client’s pH is elevated, and HCO₃ is within the normal range, which does not indicate metabolic acidosis.

Choice D Reason:

Metabolic alkalosis is indicated by a high pH (above 7.45) and a high HCO₃ (above 28 mEq/L). This condition results from an excess of bicarbonate or a loss of acids. The client’s pH is elevated, but HCO₃ is within the normal range, which does not support a diagnosis of metabolic alkalosis.

Choice A Reason:

Taking aspirin is generally not recommended for pain management in polycystic kidney disease (PKD) patients. Aspirin can cause gastrointestinal bleeding and may affect kidney function, which is already compromised in PKD patients. Instead, acetaminophen is often recommended for pain relief.

Choice B Reason:

Reducing dietary fiber intake is not typically advised for PKD patients. In fact, a balanced diet with adequate fiber is important for overall health and can help manage symptoms such as constipation, which can be a concern for PKD patients.

Choice C Reason:

Applying dry heat to the abdomen can help alleviate pain associated with PKD. Heat therapy can relax muscles and reduce discomfort caused by the enlarged kidneys and cysts. This non-pharmacological approach is safe and can be effective in managing pain.

Choice D Reason:

Checking weight once per week is not sufficient for PKD patients. Regular monitoring of weight is important to detect fluid retention and other complications. It is generally recommended to check weight more frequently, such as daily, to promptly identify any significant changes.