A patient is on a ventilator. Which situation warrants immediate intervention by the nurse?
ABG
pH 7.35-7.45
pa02 80-100 mg Hg
PC02 35-45 mm Hg
PHCO3 22-26meQ/L
The ABG results are pH 7.41. Pa02 93. PaCO2 35, and HCO3 24.
The client's pulse oximeter reading is 91% with a consistent waveform
There is no manual resuscitation bag is at the client's bedside.
The patient is receiving continuous IV sedation at 150 mL/hr. There's currently 100 ml remaining of the infusion.
The Correct Answer is C
A. The ABG results are pH 7.41, PaO2 93, PaCO2 35, and HCO3 24: These ABG values are all within normal ranges:
pH 7.35–7.45 (normal)
PaO2 80–100 mmHg (normal)
PaCO2 35–45 mmHg (normal)
HCO3 22–26 mEq/L (normal)
These results indicate stable respiratory function and do not warrant immediate intervention.
B. The client's pulse oximeter reading is 91% with a consistent waveform: While 91% is slightly lower than the ideal oxygen saturation (usually above 92%–94%), it is still above the critical threshold of 90%. This could be an acceptable level in some patients on a ventilator, particularly if there are no signs of distress or other abnormalities.
C. There is no manual resuscitation bag at the client's bedside: This is a critical situation. A manual resuscitation bag (Ambu bag) is essential for emergency resuscitation if the ventilator fails or if there is an unexpected issue with the patient's airway. Not having a manual resuscitation bag at the bedside is a safety concern that warrants immediate intervention, as it could delay life-saving measures in an emergency.
D. The patient is receiving continuous IV sedation at 150 mL/hr. There's currently 100 mL remaining of the infusion: While it's important to monitor IV sedation infusions, this situation does not immediately warrant intervention. The nurse can track the remaining infusion and ensure there is an adequate supply or order a new infusion if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Insertion of a tracheostomy to maintain the airway: This is not the first step in the management of hypercapnic respiratory failure. A tracheostomy is usually considered in cases where prolonged mechanical ventilation is required or for patients who need long-term airway support. It would not be immediately prescribed in this situation.
B. Use of noninvasive positive pressure ventilation (BIPAP): The client is showing signs of hypercapnic respiratory failure, indicated by lethargy, slow response to commands, and low oxygen saturation (pulse ox 84%) despite receiving oxygen via a Venturi mask. BIPAP (Bilevel Positive Airway Pressure) is a form of noninvasive ventilation that can help improve both oxygenation and ventilation by providing positive pressure to help the client breathe more effectively. It is often used in cases of hypercapnic respiratory failure, especially when the patient is alert enough to tolerate the mask.
C. Endotracheal intubation with mechanical ventilation: While this may be necessary if noninvasive ventilation (like BIPAP) is not effective, endotracheal intubation is typically considered when the patient is unable to tolerate noninvasive ventilation or if their respiratory failure worsens significantly. Given that the patient is still responsive (though lethargic), BIPAP would likely be tried first.
D. Administration of 50% Venturi mask: Increasing the oxygen concentration is unlikely to resolve the underlying issue of hypercapnia (elevated CO2 levels) in this patient. Hypercapnic respiratory failure is primarily due to inadequate ventilation, not just oxygen deficiency. Therefore, a higher concentration of oxygen may not be sufficient and would not address the need for improved ventilation.
Correct Answer is A
Explanation
A. Contact the prescriber because the current prescription is at an unsafe dose: The prescribed dose of 540 mg three times per day totals 1620 mg in 24 hours, which exceeds the maximum safe dosage of 1500 mg for pyridostigmine (Mestinon). The nurse should immediately contact the prescriber to clarify or adjust the prescription to ensure the patient is not put at risk for toxicity.
B. Instruct the patient to take their medication with juice & crackers if stomach upset occurs: While taking pyridostigmine with food may help minimize gastrointestinal upset, this is not the priority concern. The primary issue is the unsafe dosage. The nurse should focus on addressing the dosage error before providing further instructions on food intake.
C. Inform the patient that abdominal cramping & diarrhea will decrease as their body adjusts: While abdominal cramping and diarrhea are common side effects of pyridostigmine, this does not address the critical issue of the unsafe dosage. The nurse should first ensure that the prescription is safe before discussing side effects.
D. Remind the patient to take their doses on time to prevent cholinergic crisis: While it is important for patients with myasthenia gravis to take their medication on time to avoid cholinergic crisis (a potentially life-threatening condition due to excessive cholinergic activity), this is secondary to ensuring the dosage is correct. The priority action is to contact the prescriber regarding the unsafe dose.
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