A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement.
Which of the following findings should the nurse identify as effectiveness of the treatment?

Choice A rationale:

A respiratory rate of 9/min and shallow respirations are indicative of hypoventilation, which can lead to an accumulation of carbon dioxide (CO2) in the blood. This condition results in respiratory acidosis (Choice D). In respiratory acidosis, the arterial pH is decreased (acidic) while the PaCO2 (partial pressure of carbon dioxide) is elevated.

Choice B rationale:

Respiratory alkalosis (Choice B) is characterized by a low PaCO2 and an elevated pH due to hyperventilation. Shallow respirations and a respiratory rate of 9/min do not align with this condition, as it typically involves rapid and deep breathing.

Choice C rationale:

Metabolic alkalosis (Choice C) results from a primary excess of bicarbonate (HCO3-) in the blood and is not associated with the given respiratory patterns. Shallow respirations and a low respiratory rate are more likely to lead to an accumulation of CO2, causing respiratory acidosis (Choice D).

Choice D rationale:

The correct answer is choice D. Shallow respirations and a respiratory rate of 9/min indicate hypoventilation, leading to an accumulation of CO2 in the blood. This condition results in respiratory acidosis, where the arterial pH is decreased. The body's compensatory response is to retain bicarbonate to normalize pH, but this can result in an elevated HCO3- level. The primary acid-base imbalance in this case is respiratory acidosis. .

Choice A rationale:

Having the client cough and expectorate secretions is a reasonable intervention for managing respiratory distress, but it is not the top priority. The nurse should first assess the client's overall respiratory status to determine the severity of the problem.

Choice B rationale:

Instructing the client to use a pursed-lip breathing technique is a helpful strategy to improve breathing in some cases. However, it should not be the top priority when a client is experiencing difficulty breathing. Assessment should come first.

Choice C rationale:

Increasing the oxygen flow to 3 L/min without a proper assessment is not advisable. It's essential to evaluate the client's respiratory status before making any adjustments to the oxygen therapy.

Choice D rationale:

"Evaluate the client's respiratory status" is the correct response. When a client with COPD and oxygen therapy reports difficulty breathing, the nurse's priority is to assess the client's respiratory status. This assessment will help determine the cause of the breathing difficulty and guide appropriate interventions. The nurse should also check the oxygen saturation levels, respiratory rate, and auscultate lung sounds to assess the severity of the issue.