The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. Which intervention should the nurse expect to be prescribed to correct this problem?
Encourage the patient to breathe in and out slowly into a paper bag.
Immediately administer oxygen via a mask and monitor oxygen saturation.
Anticipate the administration of intravenous sodium bicarbonate.
Prepare to start an intravenous fluid bolus using isotonic fluids.
The Correct Answer is A
The correct answer is choice A: Encourage the patient to breathe in and out slowly into a paper bag.
Choice A rationale: The patient’s arterial blood gas (ABG) results indicate respiratory alkalosis, as evidenced by the elevated pH (7.48) and decreased PaCO2 (25 mm Hg). Respiratory alkalosis often results from hyperventilation, which can occur due to anxiety. Breathing into a paper bag helps to increase CO2 levels in the blood, thereby correcting the alkalosis.
Choice B rationale: Administering oxygen is not appropriate in this scenario because the patient’s PaO2 is already elevated (110 mm Hg), indicating that oxygenation is not the issue. Providing additional oxygen would not address the underlying problem of hyperventilation and respiratory alkalosis.
Choice C rationale: Intravenous sodium bicarbonate is used to treat metabolic acidosis, not respiratory alkalosis. In this case, the patient’s HCO3 is within the normal range (24 mEq/L), indicating that there is no metabolic acidosis present.
Choice D rationale: Starting an intravenous fluid bolus with isotonic fluids is not indicated for correcting respiratory alkalosis. This intervention is more appropriate for patients experiencing hypovolemia or dehydration, which is not suggested by the patient’s ABG results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Widened QRS Complexes.
Choice A rationale:
Hyperactive deep tendon reflexes are not typical findings in respiratory acidosis. They are more commonly associated with conditions like hypocalcemia or hypercalcemia.
Choice B rationale:
Warm, flushed skin is not directly related to respiratory acidosis. It is not a typical manifestation of this acid-base imbalance.
Choice C rationale:
Widened QRS complexes on an ECG are characteristic findings in respiratory acidosis. Acidosis can lead to changes in the electrical conduction of the heart, resulting in QRS complex widening.
Choice D rationale:
Bounding peripheral pulses are not directly associated with respiratory acidosis. They may be seen in conditions like hyperthyroidism or anemia but are not specific to respiratory acidosis. Remember, always interpret lab results and clinical findings in the context of the patient's overall condition, medical history, and other relevant factors to provide the best care possible.
Correct Answer is C
Explanation
Choice A rationale:
Sodium level is a laboratory parameter that can be helpful in assessing fluid balance, but it does not directly measure fluid retention. Abnormal sodium levels may indicate fluid imbalances, but it is not the most reliable measure of fluid retention.
Choice B rationale:
Tissue turgor refers to the skin's elasticity, and it can be used to assess dehydration rather than fluid retention. Poor turgor may indicate dehydration, but it does not specifically measure fluid volume increase.
Choice C rationale:
Daily weight is a reliable measure of fluid retention. An increase in weight over a short period may indicate fluid accumulation in the body, while a decrease in weight could signify fluid loss. It is essential to monitor weight consistently under standardized conditions (e.g., same time, same clothing) for accurate assessment.
Choice D rationale:
Intake and output records provide information about fluid intake and output but may not always reflect fluid retention accurately. It is helpful for assessing fluid balance, but daily weight is a more direct and reliable measure of fluid retention.
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