A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.1, PaCO2 70 mm Hg, and HCO3 22 mEq/L. Which intervention does the nurse implement first?

Assess the airway.

Administer prescribed bronchodilators.

Administer prescribed mucolytics.

Provide oxygen.

Answer and Explanation

The Correct Answer is A

A.   Assessing the airway is always a priority in any client care situation, especially when there are respiratory abnormalities such as respiratory acidosis. Ensuring a patent airway is crucial to maintain adequate oxygenation and ventilation.
B.   Bronchodilators are typically used to treat conditions such as bronchoconstriction in asthma or chronic obstructive pulmonary disease (COPD). However, in the context of respiratory acidosis with an elevated PaCO2, the primary issue is not bronchoconstriction but rather impaired gas exchange due to inadequate ventilation.
C.   Mucolytics are medications used to thin mucus and facilitate its removal from the respiratory tract. While they can be beneficial in conditions with thick secretions, they do not address the underlying cause of respiratory acidosis, which is inadequate CO2 elimination.
D.   Providing oxygen can help improve oxygenation in clients with respiratory acidosis. However, it is important to note that oxygen alone will not correct the underlying cause of respiratory acidosis (elevated PaCO2). Oxygen therapy is supportive and helps to improve oxygen delivery to tissues while other interventions are addressed.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Postoperative patients often experience muscle tension and discomfort due to lying in one position for an extended period. A gentle back massage can help relieve muscle stiffness, promote relaxation, and improve circulation. It is a non-invasive comfort measure that can enhance the client's overall well- being.
B. Teaching relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation can help the client manage pain, reduce anxiety, and promote faster recovery. These techniques are beneficial postoperatively as they encourage relaxation and improve overall comfort.
C. Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) or pneumonia due to shallow breathing or inadequate lung expansion. Coughing and deep breathing exercises help to clear secretions, improve lung function, and prevent respiratory complications. It is typically recommended to perform these exercises every hour to maintain lung expansion and prevent complications.
D. Encouraging the client to turn every 2 hours (D), not every 4 hours, is essential to prevent pressure ulcers and promote circulation.
E. Postoperative pain management is essential for the client's comfort and recovery. Pain can interfere with the client's ability to cough, deep breathe, and move effectively, which may increase the risk of complications. Administering analgesics as needed helps to control pain, improve overall comfort, and promote participation in necessary activities such as coughing, deep breathing, and turning.

A. Give the client a back massage. B. Teach the client relaxation techniques. C. Assist the client to cough and deep breathe ev D. Encourage the client to turn every 4 hr. E. Administer analgesics as needed.

Correct Answer is ["B","C","E"]

Explanation

A. A back massage (A) can be soothing and may help with circulation, but it's not typically a priority immediately postoperative.
B. Teaching relaxation techniques such as deep breathing exercises, guided imagery, or progressive muscle relaxation can help the client manage pain, reduce anxiety, and promote faster recovery. These techniques empower the client to actively participate in their comfort and recovery process.

C. Postoperative clients are at risk of developing respiratory complications such as atelectasis (partial lung collapse) due to shallow breathing. Coughing and deep breathing exercises help to expand lung volume, clear secretions, and prevent respiratory complications. It's important to encourage and assist the client in performing these exercises regularly.
D. Encouraging the client to turn every 4 hours helps prevent pressure ulcers and promotes good circulation, but turning might be more frequent depending on the surgery and the client's condition.
E. Pain management is crucial for postoperative comfort and recovery. Administering analgesics as needed helps to control pain effectively, which is essential for the client to participate in activities such as deep breathing, coughing, and moving, thereby reducing the risk of complications.

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A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.1, PaCO2 70 mm Hg, and HCO3 22 mEq/L. Which intervention does the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is planning care for a client who is 4 hr postoperative. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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