A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client?

Ask a family member to interpret what the client is trying to communicate.

Ask the physician to wean the client off the mechanical ventilator to allow the client to talk.

Ask the client to write, use a picture board, or spell words with an alphabet board.

Assure the client that everything will be all right and that he shouldn't become upset.

Answer and Explanation

The Correct Answer is C

A. Ask a family member to interpret what the client is trying to communicate: While family members can sometimes help, the nurse should directly facilitate communication with the client using appropriate tools.

B. Ask the physician to wean the client off the mechanical ventilator to allow the client to talk: Weaning off a ventilator should only be done based on medical stability, not solely for communication purposes.

C. Ask the client to write, use a picture board, or spell words with an alphabet board: These tools can help non-verbal clients on mechanical ventilation express themselves and reduce frustration.

D. Assure the client that everything will be all right and that he shouldn't become upset: This response is dismissive and does not address the client's need to communicate.

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Correct Answer is B

Explanation

A. Respiratory acidosis: Respiratory acidosis would present with a low pH (below 7.35) and a high PaCO2 (above 45 mmHg).

B. Respiratory alkalosis: This ABG shows a high pH (7.51), low PaCO2 (32 mmHg), and normal HCO3- (26 mEq/L), indicating respiratory alkalosis, typically due to hyperventilation.

C. Metabolic acidosis: Metabolic acidosis would present with a low pH and low HCO3-, but in this case, the HCO3- is normal.

D. Metabolic alkalosis: Metabolic alkalosis would show a high pH and high HCO3-, but the HCO3- in this ABG is normal.

A. Partially compensated Metabolic Alkalosis B. Fully compensated Metabolic Acidosis C. Fully compensated Respiratory Acidosis D. Partially compensated Respiratory Alkalosis

Correct Answer is C

Explanation

A. Partially compensated Metabolic Alkalosis: This is incorrect because the pH is within normal limits (7.35-7.45), and the elevated PaCO2 and bicarbonate suggest a respiratory issue rather than a metabolic one.

B. Fully compensated Metabolic Acidosis: This is incorrect because the primary disturbance is respiratory, not metabolic. A compensated metabolic acidosis would typically show a low PaCO2 as compensation.

C. Fully compensated Respiratory Acidosis: Correct. The pH is within the normal range, indicating full compensation. The elevated PaCO2 and bicarbonate reflect a chronic respiratory acidosis that has been compensated by the kidneys.

D. Partially compensated Respiratory Alkalosis: This is incorrect because in respiratory alkalosis, the PaCO2 would be low, not high.

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A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Interpret the following ABG: PH 7.51 Pa02 88 PaC02 32 Bicarb (HC03-) 26 Sa02 95%

Correct Answer is B

Explanation

A nurse reviews the following ABG result: pH 7.37 PaO2 84 PaCO2 54 Bicarbonate: 31 Saturation: 95% What is the interpretation of this ABG?

Correct Answer is C

Explanation

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