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Respiratory alkalosis: Respiratory alkalosis occurs when there is excessive loss of carbon dioxide (CO₂), usually from hyperventilation. The PaCO₂ would be low (typically below 35 mm Hg) and the pH would be elevated above 7.45. However, this client has a high PaCO₂ (68 mm Hg) and a low pH (7.22), which points acidosis, not alkalosis.

Metabolic alkalosis: Metabolic alkalosis results from increased bicarbonate (HCO₃⁻) or excessive loss of hydrogen ions (as in vomiting or diuretic use). While this client’s bicarbonate is slightly elevated (28 mEq/L), it reflects renal compensation for CO₂ retention, not a primary metabolic process.

Metabolic acidosis: Metabolic acidosis is characterized by a low pH and low bicarbonate (HCO₃⁻), often with compensatory hyperventilation to lower PaCO₂. In this case, bicarbonate is not decreased, and the respiratory rate is depressed rather than increased.

Empty the collection container every shift: The collection chamber should never be emptied or opened, as this risks breaking the sterile system and introducing infection or air into the pleural space. When the chamber fills to the prescribed level, the entire unit should be replaced.

Clamp the chest tubes if it becomes disconnected: Clamping a chest tube can lead to rapid accumulation of air in the pleural space, causing a tension pneumothorax—a life-threatening emergency.

Add tap water as needed to the suction control chamber: Only sterile water should be added to the suction control chamber to maintain the prescribed suction level, as tap water introduces the risk of contamination and infection.

"I will seal my lips around the mouthpiece and take slow, deep breaths.": Sealing the lips prevents medication loss, and taking slow, deep breaths ensures optimal delivery of the aerosolized drug to the lower airways. This maximizes therapeutic effectiveness and minimizes medication waste.

"I should wash the mouthpiece with warm, soapy water each day.": Daily cleaning of the mouthpiece with warm, soapy water is proper technique to prevent bacterial buildup and infection. After washing, it should be rinsed thoroughly and allowed to air-dry completely before the next use.

"I will store my nebulizer at room temperature.": Nebulizers and their medications should be stored in a clean, dry place at room temperature, away from direct sunlight and moisture, to maintain functionality and medication stability.

Place the client in left Sims' position: After a tracheostomy, the client should be positioned in semi-Fowler’s or Fowler’s position to promote lung expansion, facilitate drainage of secretions, and reduce the risk of airway obstruction.

Use clean technique when providing tracheostomy suctioning: Suctioning a fresh tracheostomy (within the first 72 hours) requires strict sterile technique to prevent infection of the surgical site and lower respiratory tract. Using clean technique increases the risk of introducing pathogens.

Clean the tracheostomy stoma with povidone-iodine: Povidone-iodine is not routinely used for tracheostomy care because it can irritate the mucosa and damage healthy tissue. Instead, the stoma should be cleaned with sterile saline or an appropriate antiseptic solution as per facility protocol.

Tidalling, fluctuations in the fluid level in the water-seal chamber: Tidalling is a normal finding in a functioning chest drainage system. It reflects normal pressure changes within the pleural cavity during breathing and indicates that the system is patent and draining properly.

Occasional bubbling in the water-seal chamber: Occasional, brief bubbling during coughing, exhalation, or repositioning is expected as residual air is expelled from the pleural space. This should subside as the lung re-expands. Intermittent bubbling, therefore, is a normal observation.

Patient respiratory status is stable and denies pain to chest tube site: A stable respiratory status and absence of pain are expected and reassuring postoperative findings. These do not indicate a complication and therefore do not require urgent reporting.

Decreasing respiratory rate: Atelectasis, or collapse of alveoli, leads to reduced gas exchange and hypoxemia. The body compensates by increasing respiratory rate—not decreasing—to improve oxygen intake.

Facial flushing: Facial flushing may occur with fever, emotional distress, or vasodilation, but it does not reflect impaired alveolar ventilation or oxygen exchange. Clients with atelectasis are more likely to appear pale or cyanotic due to hypoxemia rather than flushed.

Dry cough: While a cough can occur with atelectasis, it is often ineffective or minimal because the collapsed alveoli and shallow postoperative breathing limit cough effort. The hallmark findings are dyspnea, decreased oxygen saturation, and diminished breath sounds over the affected area.

Deep rapid breathing: Deep, rapid breathing is characteristic of metabolic acidosis, not respiratory acidosis. In metabolic acidosis, the body tries to “blow off” excess CO₂ to raise pH. In respiratory acidosis, however, ventilation is impaired, leading to CO₂ retention and shallow, ineffective respirations.

Cool, clammy skin: Cool, clammy skin may occur with shock or hypoperfusion states but is not a hallmark feature of respiratory acidosis. In acute respiratory acidosis, the main issue is CO₂ retention and resultant cerebral vasodilation, not peripheral vasoconstriction leading to clamminess.

Severe diarrhea: Severe diarrhea typically causes metabolic acidosis due to the loss of bicarbonate from the gastrointestinal tract, not respiratory acidosis. Respiratory acidosis arises from hypoventilation, lung disease, or impaired gas exchange rather than from gastrointestinal losses.

Inspiratory stridor: Stridor is a high-pitched, harsh sound typically heard during inspiration when there is upper airway obstruction, such as in laryngeal edema, foreign body aspiration, or croup. It is not a feature of pneumothorax, which affects the lower respiratory system and the lung parenchyma.

Expiratory wheeze: Wheezing occurs when there is narrowing of the airways, such as in asthma, COPD, or bronchospasm. In pneumothorax, the problem is not narrowed bronchi but air trapped in the pleural space, preventing lung expansion—so wheezes are not typical findings.

Coarse crackles: Coarse crackles indicate fluid in the airways or alveoli, as seen in pneumonia or pulmonary edema. A pneumothorax involves air, not fluid, within the pleural cavity, leading to lung collapse and loss of ventilation sounds rather than bubbling or crackling noises.