A patient presents with a diagnosis of chronic obstructive pulmonary disease (COPD). The ABG results are as follows: pH 7.32. pCO2 68, p02 78, HCO3 23. What action should the nurse take first?
Remove the client's 02 mask.
Notify the physician
Have the client breath into a paper bag
Place the patient in left side-lying position
The Correct Answer is B
A. Remove the client's O₂ mask: Removing supplemental oxygen is unsafe and may worsen hypoxia. Even though oxygen must be carefully titrated in COPD, abrupt removal is never appropriate without medical direction, especially when the client is already hypoxemic.
B. Notify the physician: The ABG shows respiratory acidosis (low pH, elevated pCO₂) with insufficient compensation and potential respiratory failure. Immediate provider notification is warranted to adjust oxygen delivery, initiate or escalate respiratory support, or evaluate for further interventions.
C. Have the client breathe into a paper bag: Paper bag breathing is used for respiratory alkalosis caused by hyperventilation, not for respiratory acidosis. This action would further elevate CO₂ and worsen the client's acid-base status.
D. Place the patient in left side-lying position: Side-lying positioning does not address the critical issue of respiratory acidosis. Instead, placing the client in high Fowler’s position might help improve ventilation, but first the provider must be notified to address the urgent ABG findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. 2–3 days:This is the correct time frame for interpreting a tuberculin skin test (Mantoux test). The induration response should be evaluated 48 to 72 hours after administration to ensure accurate results. Reading the test outside this window may lead to false negatives or unreliable interpretation.
B. 24 hours:Reading the skin test after only 24 hours may not allow sufficient time for the delayed hypersensitivity reaction to develop. The immune response that causes induration typically peaks at 48–72 hours.
C. 1 week:Waiting a full week exceeds the ideal time frame for interpretation. By this point, the reaction may have subsided, leading to an inaccurate or unreadable result. Follow-up must occur within 2–3 days.
D. 1 month:A return after one month is far too late to interpret the results. The test site would have long since returned to baseline, making accurate evaluation impossible and necessitating repeat testing.
Correct Answer is A
Explanation
A. White blood cell (WBC) count, arterial blood gases (ABGs):WBC count helps assess the presence and severity of infection, while ABGs evaluate the patient’s oxygenation and gas exchange critical factors in pneumonia. These tests directly reflect respiratory function and the inflammatory response.
B. Complete blood count (CBC), urinalysis:While a CBC includes the WBC count, the rest of the values are not directly helpful in tracking pneumonia progression. A urinalysis assesses kidney and urinary tract health, not respiratory infection, so it is not essential.
C. Electrolytes, serum creatinine:These tests provide information on renal function and electrolyte balance, which may be relevant in complex cases but are not specific indicators of pneumonia status or treatment response.
D. Partial thromboplastin time (PTT), serum potassium:PTT evaluates clotting, and serum potassium assesses electrolyte balance. Neither test provides useful information about the progression or resolution of pneumonia.
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