A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement?
Decrease expiratory flow time.
Decrease expiratory pressure.
Increase rate of ventilation.
Increase ventilator tidal volume.
The Correct Answer is C
The correct answer is choice C: Increase rate of ventilation.
Choice A rationale:
Decreasing expiratory flow time would not directly address the elevated PaCO2 levels. This intervention is more related to managing expiratory phase issues rather than correcting respiratory acidosis.
Choice B rationale:
Decreasing expiratory pressure might help with certain ventilation issues, but it does not specifically target the elevated PaCO2 and resulting acidosis.
Choice C rationale:
Increasing the rate of ventilation helps to blow off more CO2, thereby reducing PaCO2 levels and correcting the respiratory acidosis indicated by the pH of 7.26 and PaCO2 of 68 mm Hg.
Choice D rationale:
Increasing the ventilator tidal volume could also help reduce PaCO2 by increasing the amount of air exchanged with each breath. However, increasing the rate of ventilation is generally a more immediate and effective intervention for acute respiratory acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Providing information about the client's healthcare power of attorney is not the most critical piece of information to report in this situation. The immediate concern is the client's change in mental status and potential medical emergency.
Choice B rationale:
While the reason for the client's admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client's acute change in mental status.
Choice C rationale:
The nurse should be aware of the client's currently prescribed medications, but this information does not take precedence over the client's sudden onset of confusion and agitation. Immediate action is needed to address the client's altered mental status.
Choice D rationale:
Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client's immediate needs.
Correct Answer is C
Explanation
The correct answer is choice C: Ensure that the call bell is easily accessible to the client.
Choice C rationale: Ensuring that the call bell is easily accessible empowers the client to promptly request assistance if needed during the night. This promotes safety and reduces anxiety, as the client can quickly contact the nurse if they experience an urgent need to use the restroom or require any other assistance during the night.
Choice A rationale: Reassuring the client that someone will check on him hourly may provide some comfort, but it does not directly address the client's issue of urinary frequency. Ensuring easy access to the call bell is a more targeted approach to managing the client's needs.
Choice B rationale: Placing fresh water and a glass within reach on the bedside table is a good practice to maintain hydration, but it does not directly address the client's urinary frequency issue.
Choice D rationale: Offering an evening snack and oral care is essential for the client's overall well-being, but it is not directly related to managing the client's urinary frequency at night. The primary focus should be on ensuring that the client can access assistance quickly when needed.
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