A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 88 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)]
Increase ventilator tidal volume.
Decrease expiratory flow time.
Decrease expiratory pressure.
Increase rate of ventilation.
The Correct Answer is D
A. Increasing the ventilator tidal volume could improve the client's ventilation but may not adequately address the severe hypercapnia indicated by the elevated PaCO2.
B. Decreasing expiratory flow time is not a priority and may not improve ventilation effectively.
C. Decreasing expiratory pressure does not directly address the underlying problem of carbon dioxide retention.
D. Increasing the rate of ventilation is the most appropriate intervention to improve carbon dioxide elimination and correct the acid-base imbalance indicated by the low pH and high PaCO2.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Asking about sundowning may provide some insights into the client's cognitive state, but it is not directly related to the current concerns of weight loss, energy, and appetite.
B. Requesting the client to lie still is unnecessary and may hinder the assessment of their overall functional status and mobility.
C. Discussing end-of-life care options may be appropriate in certain contexts, but it is not a priority in assessing immediate functional status and nutritional concerns.
D. Questioning the client about the frequency of falls is crucial, as it may indicate underlying health issues that could be contributing to weight loss, decreased energy, and potential mobility challenges.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
This client is at risk for VTE due to several factors, including being postpartum, prolonged labor (25 hours), and potential immobility after delivery. Additionally, the presence of a 4th-degree laceration may lead to decreased mobility, increasing the risk of blood clots.
Wound Dehiscence:
The client has a 4th-degree laceration, which involves a significant degree of tissue damage and may require careful monitoring for proper healing. Factors such as infection (noted by slight fever), tension on the wound, or inadequate healing can contribute to the risk of dehiscence.-
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