A nurse is analyzing the arterial blood gas (ABG) results of a patient.


The patient’s ABGs are: pH:7.6, PaCO2:40 mm Hg, HCO3:32 mEq/L. Which of the following acid-base conditions should the nurse identify the patient is experiencing?

The correct answer is choiceD.

Choice A rationale:

Assisting the client back into bed is not the initial action.Moving the client without assessing their condition could potentially cause harm.

Choice B rationale:

Notifying the client’s provider is important, but it should be done after assessing the client’s condition to provide accurate information.

Choice C rationale:

Informing the client’s family member is not the immediate priority.The nurse should first ensure the client’s safety and assess their condition.

Choice D rationale:

Obtaining the client’s vital signs is the initial action.This helps assess the client’s current condition and determine if there are any immediate medical needs.

Choice B rationale:

Phlebitis is the inflammation of a vein, often caused by an IV catheter. It's characterized by redness, swelling, warmth, and pain along the vein.

Promptly discontinuing the IV infusion is crucial to prevent further irritation and potential complications such as: Thrombophlebitis (inflammation with clot formation)

Infection

Infiltration (leakage of fluids into surrounding tissues) Extravasation (leakage of vesicant or damaging medications)

Continuing the infusion could exacerbate the inflammation and increase the risk of these complications.

Choice A rationale:

Elevation of the extremity can help reduce swelling, but it does not address the underlying inflammation. It's often used as an adjunct measure after discontinuing the IV.

Choice C rationale:

Warm, moist compresses can provide some comfort and potentially promote blood flow, but they are not recommended as a first-line treatment for phlebitis. They may even worsen inflammation in some cases.

Choice D rationale:

Inserting an IV catheter in the opposite extremity is necessary if the patient still requires IV therapy, but it should not be done before addressing the phlebitis in the current site. This could lead to multiple sites of inflammation and increased risk of complications.