A nurse is reviewing the laboratory results of a client who was an unrestrained passenger in a motor-vehicle crash. The ABG results are as follows: pH 7.32, HCO3 24 mEq/L, PaCO2 48 mm Hg. The nurse should identify the client is experiencing which of the following acid-base imbalances?

A. Check skin temperature distal to the injury with the dorsum of the hand.: Assessing skin temperature distal to the injury is an important part of evaluating neurovascular status. It helps to identify any changes in circulation or potential complications like ischemia. The dorsum of the hand is commonly used as it provides a good comparison to the temperature of the affected extremity.

B. Press the heel of the foot to determine capillary refill.: While capillary refill is an important assessment, it is usually measured by pressing the nail beds or pads of the fingers and toes, not by pressing the heel. This method does not provide a reliable indication of neurovascular status.

C. Monitor sensation by palpating the pad of the great toe with a blunt needle.: While assessing sensation is important, it is typically done using a light touch or pinprick, rather than palpating with a blunt needle. The use of a needle is not standard practice for this type of assessment.

D. Compare the color of the skin proximal to the injury with the other extremity.: Comparing the skin color distal to the injury with the unaffected extremity is more relevant for evaluating neurovascular status. Proximal comparison is less effective in assessing circulation and potential issues related to the injury.

A) Aspirin can be given to decrease the fever caused by varicella: Aspirin should not be used in children with varicella (chickenpox) due to the risk of Reye’s syndrome, a rare but serious condition that can cause liver and brain damage. Instead, acetaminophen or ibuprofen is recommended for fever management in these cases.

B) Maintaining a warm environment decreases the eruption of lesions: Maintaining a warm environment does not affect the eruption of varicella lesions and could potentially exacerbate discomfort. A cool environment and loose, comfortable clothing are preferred to help alleviate itching and discomfort.

C) Varicella has an incubation period of 1 to 3 days: The incubation period for varicella is typically 10 to 21 days after exposure. The shorter period of 1 to 3 days is not accurate for varicella and does not reflect the standard incubation period of this disease.

D) An antihistamine can be administered to decrease pruritus: Antihistamines are effective in managing itching (pruritus) associated with varicella lesions. They can help provide relief from the discomfort caused by the rash, making this an appropriate intervention.