A nurse is caring for a patient who has the following arterial blood values: pH 7.12, PaO 56 mm Hg, PaCO 65 mm Hg, and HCO - 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values?

A. Assess the patient’s respiratory rate, rhythm, depth:

This is the correct action to take first. Hypokalemia can lead to respiratory muscle weakness, which can result in respiratory compromise or failure. Assessing the patient's respiratory rate, rhythm, and depth will help determine if there are any signs of respiratory distress or impending respiratory failure.

B. Call the healthcare provider:

While it's important to involve the healthcare provider, especially if there is a significant change in the patient's condition, assessing the patient's immediate respiratory status takes priority to ensure prompt intervention if respiratory distress is present.

C. Document findings and monitor the patient:

Documenting findings and ongoing monitoring are essential steps, but they come after addressing the patient's immediate needs, such as assessing respiratory status in this case.

D. Measure the patient’s pulse and blood pressure:

While vital signs are important, they may not immediately address the potential respiratory compromise associated with hypokalemia-induced muscle weakness. Assessing respiratory status is more directly relevant to the observed change in handgrip strength.

A. Inform the client that the recovery nurse will instruct them how to manage postoperative pain:

This is an important aspect of postoperative care, but it is typically addressed by the post-anesthesia care unit (PACU) or recovery nurse after surgery rather than in the preoperative education phase. While pain management education is crucial, the focus of preoperative education is usually on what to expect before, during, and immediately after surgery.

B. Remind the client they will return to their room after surgery:

This information is part of the preoperative instructions and helps alleviate anxiety by providing clarity about the post-surgical process. However, it may not be the most critical aspect of preoperative education compared to other options.

C. Provide instructions about how to cough and deep breathe effectively:

This is a key nursing intervention to include in preoperative education. Teaching the client how to cough and deep breathe effectively helps prevent postoperative complications such as atelectasis and pneumonia. These breathing techniques are typically taught preoperatively to ensure the client understands and can perform them correctly after surgery.

D. Notify the client that they will receive a food tray in the recovery room:

While it's important for the client to understand the postoperative diet plan, including any dietary restrictions or instructions, this information is usually provided after surgery rather than in the preoperative education phase.