A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.32. PaO2 85 mm Hg, PaCO2 34 mm Hg. and HCO3⁻16 mEq/L. What action should the nurse take next?
Encourage deep breathing exercises.
Administer sodium bicarbonate intravenously.
Place the client on a ventilator.
Increase the client's oxygen flow rate.
The Correct Answer is B
Rationale:
A. Deep breathing exercises would help correct respiratory acidosis by eliminating CO₂, but this client has metabolic acidosis.
B. The ABG shows metabolic acidosis (low pH 7.32, low HCO₃⁻ 16, low PaCO₂ as partial compensation). The priority treatment may include IV sodium bicarbonate in severe cases to buffer excess acid.
C. Mechanical ventilation is indicated for respiratory failure, not metabolic acidosis.
D. Oxygen therapy is unnecessary since the PaO₂ is normal (85 mm Hg).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Obtaining a sputum culture is essential to identify the causative pathogen and guide appropriate antibiotic or antifungal therapy in a client with recurring pneumonia and immunocompromised status.
B. Positioning the head of the bed at 10 degrees is insufficient; a semi- to high-Fowler’s position (30–90 degrees) is recommended to promote lung expansion and reduce aspiration risk.
C. Coughing and deep breathing every 8 hr is inadequate; these interventions should be performed every 1–2 hr while awake to effectively mobilize secretions.
D. Encouraging only 1500 mL/day of fluids may be insufficient; clients with pneumonia generally require adequate hydration to help thin secretions, unless restricted for another medical reason.
Correct Answer is A
Explanation
Rationale:
A. The ABGs show respiratory alkalosis (pH 7.50, PaCO₂ 29) with hypoxemia (PaO₂ 60, SaO₂ 86%). The priority is to administer oxygen via face mask to correct hypoxemia.
B. Mechanical ventilation may be needed if oxygen therapy is ineffective, but it is not the first action.
C. A sedative is not appropriate because the hyperventilation is compensatory for impaired oxygenation.
D. Assessing for pulmonary embolism is important (risk factors: oral contraceptives, smoking, sudden dyspnea), but ensuring oxygenation takes priority in the immediate situation.
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