A client is admitted with a suspected opioid overdose and a respiratory rate of 6 breaths per minute. Which of the following data would the nurse anticipate? (SELECT ALL THAT APPLY)
pH 7.29
Pa CO2 54
pH 7.51
PaO2 72
Pa CO2 31
Correct Answer : A,B
A. pH 7.29: A respiratory rate of 6 breaths per minute suggests hypoventilation, which can lead to respiratory acidosis due to retention of carbon dioxide (CO2). A decrease in pH (acidosis) is expected in this scenario.
B. PaCO2 54: In respiratory acidosis, PaCO2 levels are elevated due to inadequate ventilation, leading to CO2 retention. Therefore, an elevated PaCO2 level would be anticipated in this situation.
C. pH 7.51: A pH of 7.51 indicates alkalosis, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
D. PaO2 72: Oxygenation may be impaired in opioid overdose due to respiratory depression, but this PaO2 level is within the normal range. Hypoxemia is not typically a prominent feature of respiratory acidosis unless there are concurrent respiratory conditions or complications. Therefore, this choice is not anticipated.
E. PaCO2 31: A PaCO2 level of 31 indicates hypocapnia, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Directly asking the client how they learn best is a straightforward and effective approach for assessing their learning style preference. This allows the client to self-report their preferences, which can provide valuable insight into their preferred learning modalities, such as visual, auditory, or kinesthetic learning.
B. While assisting the client in learning skills from simple to complex can provide valuable information about their current level of understanding and skill mastery, it may not directly assess their learning style preference. This approach focuses more on the progression of learning rather than the client's preferred learning modalities.
C. Observing the client's interactions with others can provide some clues about their communication style and social preferences but may not necessarily directly assess their learning style preference. Learning style preference encompasses how individuals prefer to receive and process information, which may not be fully captured through social interactions alone.
D. Asking the client to read from a brochure primarily assesses their ability to process written information and may provide some insight into their literacy skills. However, it does not necessarily assess their preferred learning style, as individuals may have different preferences for how they prefer to receive and process information beyond reading.
Correct Answer is B
Explanation
B. When a client experiences symptoms of extravasation, such as pain, burning, and swelling, especially with a vesicant medication, the priority is to stop the infusion and remove the catheter immediately to prevent further tissue damage. Removing the catheter promptly helps minimize the amount of medication that may have leaked into the surrounding tissues.
A. Elevating the extremity on a pillow may help reduce swelling and discomfort in some cases, but it is not the first action the nurse should take when a vesicant medication has caused pain, burning, and swelling at the IV site.
C. Keeping the catheter in place is not advisable when extravasation has occurred, especially with a vesicant medication. Continuing the infusion could lead to further tissue damage and exacerbate the client's symptoms. Removing the catheter is necessary to prevent additional medication from entering the surrounding tissues.
D. While applying a cool compress may provide temporary relief from discomfort, it is not the first action the nurse should take when managing extravasation caused by a vesicant medication. The priority is to stop the infusion, remove the catheter, and assess the extent of tissue damage. Cool compresses may be used after the catheter removal to help reduce swelling and discomfort.
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