Arterial blood gases on a postoperative client with pneumonia indicate the client is in respiratory acidosis. To best improve this acid-base imbalance, which intervention should the nurse implement?

Discontinue use of supplemental oxygen

Encouraging use of incentive spirometer

Implement fluid restrictions

Administering an antitussive agent

Answer and Explanation

The Correct Answer is B

A. Discontinue use of supplemental oxygen: This option is incorrect because supplemental oxygen is used to increase the oxygen levels in the blood, which is not directly related to addressing respiratory acidosis. In respiratory acidosis, the problem is primarily with the elimination of CO2 rather than oxygenation.
B. Encouraging use of incentive spirometer: This is the correct choice as using an incentive spirometer helps improve lung expansion and promotes alveolar ventilation, which aids in reducing CO2 levels in the blood, thereby addressing respiratory acidosis.
C. Implement fluid restrictions: This option is not suitable because fluid restrictions do not directly address the underlying issue of respiratory acidosis. Fluid restrictions might be necessary for other conditions, but they are not effective in correcting respiratory acid-base imbalances.
D. Administering an antitussive agent: This is incorrect because antitussive agents suppress cough reflexes, which can be counterproductive. In respiratory acidosis, coughing is often a protective mechanism to help clear secretions, so suppressing it may worsen the acid-base imbalance.

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Correct Answer is B

Explanation

A. Infiltration: Infiltration occurs when IV fluid or medication leaks into the surrounding tissue, typically causing swelling and coolness, but not usually a cord-like vein or a reddened streak.
B. Phlebitis: This is the correct choice. Phlebitis is inflammation of the vein, evidenced by tenderness, burning, swelling, and a reddened streak along the vein. The cord-like vein indicates inflammation.
C. Extravasation: Extravasation involves the leakage of vesicant drugs into surrounding tissue, which can cause severe tissue damage, but usually involves more than just a cord-like vein and reddened streak.
D. Infection: Infection typically presents with more systemic signs like fever and could involve purulent discharge, which is not described in this scenario.

A. Discard the container of formula every 12 hours B. Irrigate the tube with sterile water before administering medications C. Measure & record the residual volume after each feeding D. Keep head of bed elevated 30 degrees

Correct Answer is D

Explanation

A. Discard the container of formula every 12 hours: While this is important for preventing contamination, it does not directly address the risk of aspiration.
B. Irrigate the tube with sterile water before administering medications: This helps maintain tube patency and prevent clogging but does not significantly impact the prevention of aspiration.
C. Measure & record the residual volume after each feeding: Monitoring residuals is crucial for assessing gastric emptying and preventing overfeeding but does not directly prevent aspiration.
D. Keep head of bed elevated 30 degrees: This is the correct choice. Elevating the head of the bed reduces the risk of aspiration by ensuring that gravity helps keep the feeding in the stomach and minimizes the risk of reflux into the esophagus.

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Arterial blood gases on a postoperative client with pneumonia indicate the client is in respiratory acidosis. To best improve this acid-base imbalance, which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After having an intravenous (IV) line in place for 72 hours, a client complains of tenderness, burning, and swelling. Assessment of the IV site reveals a cord-like vein and a reddened streak. The nurse identifies that these findings indicate what complication?

Correct Answer is B

Explanation

A nurse is caring for a client receiving continuous enteral feedings via a gastrostomy tube. Which nursing intervention is most important to help prevent aspiration?

Correct Answer is D

Explanation

The nurse is reviewing serum laboratory test results of a client receiving diuretic therapy. The nurse determines the client is at risk for electrolyte imbalance based on which result(s)? (Select all that apply)

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