A nurse is caring for an infant with a tracheoesophageal fistula who is scheduled for surgery.
What actions should the nurse anticipate taking in the pre-operative and intra-operative period? (Select all that apply)

Choice A rationale

A pO2 of 75, pCO2 of 40, and HCO3 of 28 would be within normal limits for an infant. This would not typically be expected in an infant with a history of bronchopneumonia, as this condition often causes hypoxemia (low blood oxygen levels)78.

Choice B rationale

A pO2 of 55, pCO2 of 50, and HCO3 of 30 would indicate respiratory acidosis, which can occur in conditions like bronchopneumonia. The low pO2 indicates hypoxemia, while the high pCO2 indicates hypercapnia (excessive carbon dioxide in the bloodstream). The increased HCO3 is a compensatory mechanism to try to maintain the pH balance.

Choice C rationale

A pO2 of 75, pCO2 of 40, and HCO3 of 24 would be within normal limits for an infant. This would not typically be expected in an infant with a history of bronchopneumonia.

Choice D rationale

A pO2 of 55, pCO2 of 50, and HCO3 of 24 would indicate respiratory acidosis without compensation. However, in a chronic condition like bronchopneumonia, some degree of compensation (increased HCO3) would typically be expected.

Choice A rationale

Distracting the patient and then taking the blanket for washing might seem like a practical solution, but it can lead to trust issues. The patient may feel betrayed or tricked, which can negatively affect the therapeutic relationship between the nurse and the patient.

Choice B rationale

Acknowledging that the blanket seems to be his favorite and allowing him to keep it with him is the best course of action. The blanket likely provides comfort and security to the patient.

Taking it away, even temporarily, can cause distress. The nurse should respect the patient’s attachment to the blanket and look for alternative solutions for maintaining hygiene, such as offering to clean the blanket when the patient is ready to part with it temporarily.

Choice C rationale

Telling the patient that you want to take the blanket home to wash and that you will bring it back might not be reassuring enough for the patient. The patient may worry about the blanket getting lost or not returned, which can cause unnecessary anxiety.

Choice D rationale

Suggesting getting him another blanket so that he will not mind giving up the current one might not work. The patient’s attachment is likely to the specific blanket, not to blankets in general. A new blanket will not have the same familiarity and comforting effect as the old one.