A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement?Reference Range:
Arterial Blood Gas (ABG)
pH [Adult/child: 7.35 to 7.45]
PaCO2 [Adult/child: 35 to 45 mm Hg)
HCO- [Adult/child: 21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [Adult/child: 80 to 100 mm Hg)
Increase rate of ventilation.
Decrease expiratory flow time.
Increase ventilator tidal volume.
Decrease expiratory pressure.
The Correct Answer is A
Rationale
A. The client's pH is low (acidotic), and the PaCO2 is high (respiratory acidosis). Increasing the rate of ventilation (respiratory rate) can help to decrease PaCO2 by increasing alveolar ventilation, thereby helping to correct respiratory acidosis.
B. Expiratory flow time affects the time available for exhalation. While this may affect the overall mechanics of ventilation, it is not directly targeting the primary issue of elevated PaCO2 and acidosis.
C. Increasing tidal volume increases the volume of air delivered with each breath. This can improve ventilation efficiency but may not address the underlying problem of elevated PaCO2 unless it leads to increased minute ventilation.
D. Expiratory pressure is related to positive end-expiratory pressure (PEEP), which helps maintain alveolar recruitment and improve oxygenation. Decreasing expiratory pressure may not directly address the elevated PaCO2 and acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Iron-rich meats are beneficial for overall health, particularly for maintaining hemoglobin levels in the blood. However, they are not specifically known for their role in preventing osteoporosis. Iron is important for transporting oxygen in the blood but does not directly impact bone health.
B. Fresh fruits and vegetables are excellent sources of vitamins, minerals, and antioxidants. They contribute to overall health and well-being but are not specifically known for their direct impact on bone health unless they are rich in certain nutrients like vitamin C (found in citrus fruits and peppers) and vitamin K (found in leafy greens like spinach and kale), which can indirectly support bone health.
C. Water is essential for overall hydration and health, but it does not provide specific nutrients directly beneficial for bone health. Herbal teas can contribute to hydration and provide some antioxidant benefits, but they do not have a direct impact on osteoporosis prevention.
D. Low-fat dairy products such as milk, yogurt, and cheese are rich sources of calcium and vitamin D, which are crucial for bone health. Calcium is a primary mineral in bones, and vitamin D helps the body absorb calcium. These nutrients are essential for maintaining bone density and strength, thereby reducing the risk of osteoporosis.
Correct Answer is D
Explanation
Rationale
A. Children, especially infants, should not be given aspirin (acetylsalicylic acid) due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain.
B. This instruction is unnecessary and overly restrictive. It is not typically required to keep a healthy infant home from daycare after receiving routine vaccinations. Most infants tolerate vaccines well and are not contagious from the vaccines themselves.
C. This instruction is overly cautious. Fever after vaccinations is common and usually mild. A low-grade fever (temperature over 100.4°F or 38°C) is a common side effect of vaccinations and can be managed with appropriate measures such as giving extra fluids and using acetaminophen if recommended by the healthcare provider.
D. Applying a cool pack directly to the injection site can help relieve discomfort to the injection skin. Instead, gentle comforting measures such as cuddling or applying a clean, cool cloth to the area may help soothe discomfort.
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