A nurse is caring for a 48-year-old male client who has pneumonia on a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

The client has respiratory acidosis as indicated by a pH of 7.25 (normal: 7.35-7.45) and elevated pCO2 of 62 mm Hg (normal: 35-45 mm Hg). This condition occurs when the lungs cannot remove enough CO2, leading to its buildup and lowering the blood pH. Immediate interventions like intubation can help manage airway and ventilation. Starting an IV drip of 0.9% sodium chloride can help address dehydration, supporting hemodynamic stability. Monitoring the correct placement of the endotracheal tube ensures effective ventilation. Regular arterial blood gases assessment helps evaluate the effectiveness of interventions and the client's respiratory status.

Prepare the client for intubation: Intubation is essential to secure the airway and provide mechanical ventilation, addressing hypoxia and hypercapnia by improving gas exchange.

Start a 0.9% sodium chloride IV drip: This fluid helps in correcting dehydration, supporting blood pressure, and improving renal perfusion, which is critical in managing acid-base balance.

Correct placement of endotracheal tube: Ensuring the tube is in the correct position guarantees effective ventilation and prevents complications such as aspiration or pneumothorax.

Arterial blood gases: Regular ABG assessments help monitor the effectiveness of ventilation and guide adjustments in therapy, ensuring the client’s acid-base balance is maintained.

Metabolic acidosis is not correct as the primary issue here is a respiratory one, indicated by elevated pCO2 and lower pH.

Respiratory alkalosis is incorrect as it would present with a high pH and low pCO2, unlike the client's findings.

Metabolic alkalosis is ruled out because it would show elevated pH and bicarbonate levels, which is not seen in the client's ABG results.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

Obtaining a peak flow reading provides information about the severity of asthma, but it is not the immediate priority during an acute exacerbation.

Choice B rationale

Administering an inhaled glucocorticoid can help in managing inflammation, but it takes time to work and is not the immediate priority.

Choice C rationale

Determining the cause of the acute exacerbation is important for long-term management but is not the immediate priority.

Choice D rationale

Administering a short-acting B2-agonist (SABA) is the priority because it provides rapid bronchodilation, helping to alleviate the airway obstruction quickly.

A. Withhold oral fluids and food. B. Auscultate the client's lungs. C. Assist the client to a side-lying position. D. Provide oral hygiene.

Correct Answer is A

Explanation

Choice A rationale

Withholding oral fluids and food is the priority because it reduces pancreatic stimulation and decreases the secretion of pancreatic enzymes, preventing further autodigestion and inflammation of the pancreas.

Choice B rationale

Auscultating the client's lungs is important to check for complications such as pleural effusion or atelectasis, but it is not the immediate priority after pain management.

Choice C rationale

Assisting the client to a side-lying position can help with comfort and may ease breathing, but it does not directly address the underlying issue of pancreatic inflammation.

Choice D rationale

Providing oral hygiene is essential for overall care but does not impact the acute management of pancreatitis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is experiencing status asthmaticus.Which of the following interventions is the priority for the nurse to take?

Correct Answer is D

Explanation

A nurse is caring for a client who has acute pancreatitis.After treating the client's pain, which of the following should the nurse address as the priority intervention?

Correct Answer is A

Explanation

A nurse is caring for a child who has Addison's disease.Which of the following actions should the nurse take?

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down.Antacids do not help.The provider suspects acute pancreatitis.Which of the following laboratory test results should the nurse expect to see?

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

A nurse is assessing a client who has a pneumothorax with a chest tube in place.For which of the following findings should the nurse notify the provider?

A nurse is admitting a 45-year-old male client who has type 1 diabetes mellitus in the emergency department. Exhibits Select the findings that require immediate attention.

A nurse is assessing a client for hypoxemia during an asthma attack.Which of the following manifestations should the nurse expect?

A nurse is caring for a 65-year-old male client who is admitted to the emergency department for fatigue. Exhibits Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply)

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and is short of breath.When reviewing the client's arterial blood gases (ABGs) which of the following conditions should the nurse anticipate the client to be experiencing?