A nurse is caring for a client with pneumonia who is on mechanical ventilation and exhibits a respiratory rate of 34 breaths per minute. The client's ABG results show a pH of 7.5, PaCO2 of 28 mm Hg, and HCO3 of 22 mEq/L. Which nursing action should be prioritized?

Administer an anxiolytic.

Administer sodium bicarbonate.

Increase oxygen concentration.

Decrease the respiratory rate of the mechanical ventilator.

Answer and Explanation

The Correct Answer is D

The arterial blood gas (ABG) results indicate respiratory alkalosis, characterized by a high pH (7.5) and a low PaCO2 (28 mm Hg), while the bicarbonate remains within the normal range. In a client with pneumonia on mechanical ventilation, a respiratory rate of 34 breaths per minute suggests hyperventilation. Respiratory alkalosis occurs when excessive ventilation causes increased elimination of carbon dioxide from the body, leading to a rise in blood pH. In mechanically ventilated clients, this often results from hyperventilation due to excessive ventilator settings or patient distress.

Rationale:
A. Administering an anxiolytic may be helpful if anxiety is contributing to hyperventilation, but in this case the client is on mechanical ventilation, making ventilator settings the more direct and immediate cause to address. Priority should be given to correcting the mechanical source of excessive ventilation first. Sedation without adjusting ventilation may delay proper correction of the alkalosis.

B. Administering sodium bicarbonate is inappropriate because sodium bicarbonate is used to treat metabolic acidosis, not respiratory alkalosis. This client already has an elevated pH of 7.5, indicating alkalemia, and giving bicarbonate would worsen the imbalance. The low PaCO2 confirms that the primary problem is excessive carbon dioxide loss rather than bicarbonate deficiency.

C. Increasing oxygen concentration is not the priority because the ABG findings indicate a ventilation problem rather than an oxygenation problem. The major abnormality is low PaCO2 caused by excessive respiratory rate, not evidence of hypoxemia. Raising oxygen concentration will not correct respiratory alkalosis and may expose the client to unnecessary oxygen-related complications.

D. Decreasing the respiratory rate of the mechanical ventilator is the priority intervention because it directly addresses the cause of respiratory alkalosis. A respiratory rate of 34 breaths per minute causes excessive carbon dioxide elimination, resulting in PaCO2 of 28 mm Hg and elevated pH. Lowering the ventilator rate helps retain carbon dioxide and gradually restores normal acid-base balance.

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Free Nursing Study Resources

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

Explanation

Tracheostomy suctioning is performed to maintain airway patency by removing secretions from the tracheobronchial tree. It is an invasive procedure that can temporarily reduce oxygenation, irritate airway mucosa, and trigger vagal stimulation leading to complications such as hypoxia, bradycardia, and mucosal injury. Safe suctioning requires proper technique, sterile equipment, and careful monitoring of the client’s respiratory status before, during, and after the procedure.

Rationale:
A. Waiting 1 minute before suctioning again allows the client time to reoxygenate and recover from potential hypoxia caused by suctioning. Repeated suctioning without adequate rest can lead to oxygen desaturation, bronchospasm, and cardiac stress. This pause helps stabilize oxygen levels and reduces procedural complications.

B. Inserting the catheter slowly is important to minimize trauma to the tracheal mucosa. Rapid insertion can cause irritation, bleeding, and stimulation of the vagus nerve, which may result in bradycardia or coughing. Gentle insertion ensures safer navigation of the airway and reduces patient discomfort.

C. Disposing of the suction catheter after each use is a key infection control practice when using sterile suction technique for tracheostomy care. Reusing a catheter increases the risk of introducing pathogens into the lower respiratory tract. Proper disposal prevents cross-contamination and reduces the risk of ventilator-associated or tracheostomy-related infections.

D. Suctioning at set intervals based on a schedule is not recommended because suctioning should be performed based on clinical need rather than routine timing. Unnecessary suctioning can damage airway mucosa and cause hypoxia. Indications include audible secretions, visible mucus, or signs of respiratory distress.

E. Performing hyperoxygenation before suctioning is essential to prevent hypoxemia during the procedure. Increasing oxygen delivery prior to suctioning helps offset the temporary loss of oxygen during catheter insertion and secretion removal. This practice reduces the risk of oxygen desaturation and cardiac complications.

A. WBC count of 4,800 mm3 B. WBC count of 500 mm3 C. Hemoglobin level of 11.5 g/dL D. Platelet count of 150,000 mm3

Correct Answer is C

Explanation

Bone marrow suppression leads to decreased production of blood components, including red blood cells, white blood cells, and platelets. The specific abnormality depends on the affected cell line. Epoetin alfa is used to stimulate red blood cell production in the bone marrow, particularly in clients with anemia related to chronic kidney disease, chemotherapy, or bone marrow suppression. Therefore, improvement is best reflected by an increase in hemoglobin levels.

Rationale:
A. A WBC count of 4,800 mm³ indicates a normal or near-normal white blood cell level, but it does not reflect the therapeutic effect of epoetin alfa. This medication does not stimulate leukocyte production. WBC changes are more relevant to growth factors like filgrastim, not erythropoiesis-stimulating agents.

B. A WBC count of 500 mm³ indicates severe neutropenia and significant bone marrow suppression. This reflects a high risk for infection and does not demonstrate improvement. It is unrelated to the action of epoetin alfa, which targets red blood cell production.

C. A hemoglobin level of 11.5 g/dL indicates improvement because epoetin alfa stimulates erythropoiesis, increasing red blood cell production. This rise in hemoglobin suggests improved oxygen-carrying capacity and reduced anemia. It reflects the intended therapeutic outcome of the medication.

D. A platelet count of 150,000 mm³ is within normal limits but does not reflect the action of epoetin alfa. Platelet production is regulated by different mechanisms and medications such as thrombopoietin agonists or oprelvekin. Therefore, it is not an appropriate indicator of response to epoetin alfa therapy.

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A nurse is caring for a client with pneumonia who is on mechanical ventilation and exhibits a respiratory rate of 34 breaths per minute. The client's ABG results show a pH of 7.5, PaCO2 of 28 mm Hg, and HCO3 of 22 mEq/L. Which nursing action should be prioritized?

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Naxlex Comprehensive Predictor Exams

Which of the following actions should a nurse perform when suctioning clients with tracheostomy tubes, according to best practices? Select All that Apply.

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

Explanation

A nurse is reviewing the laboratory values of a client with bone marrow suppression and is receiving epoetin alfa. Which of the following values would indicate an improvement in the client's condition?

Correct Answer is C

Explanation

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