Reference Range: 1329545.
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 B
Choice A rationale:
Decreasing expiratory flow time is not the appropriate intervention in this case. The client's pH and PaCO2 levels suggest respiratory acidosis, which indicates inadequate ventilation. Increasing expiratory flow time might exacerbate the acidosis by reducing ventilation.
Choice C rationale:
Increasing the rate of ventilation (respiratory rate) is a potential intervention to improve the client's acid-base balance. However, it should be done cautiously and under medical supervision to avoid respiratory alkalosis. It is not the first-line intervention in this scenario.
Choice D rationale:
Increasing the ventilator tidal volume may help improve ventilation, but it should also be done under medical guidance to prevent barotrauma. It is not the initial intervention to address the client's respiratory acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Nosocomial transmission in the medical area. Rationale: Nosocomial transmission refers to infections that are acquired in healthcare settings. While it's essential for healthcare professionals to be aware of this risk, the client's presentation of diarrhea in a hurricane disaster area is more likely due to environmental factors rather than hospital-acquired infection.
Choice B rationale:
Food contamination from floodwaters. Rationale: In the aftermath of a hurricane, floodwaters can carry contaminants and pathogens, leading to food contamination. This is a significant concern, and the nurse should educate the client about the potential risks associated with consuming food exposed to floodwaters. However, the primary source of contamination for diarrhea is typically waterborne pathogens, which is addressed in choice C.
Choice C rationale:
Drinking water contaminated by sewage. Rationale: During natural disasters like hurricanes, sewage systems can become compromised, leading to the contamination of drinking water sources. This contamination poses a significant risk for diarrheal illnesses, as sewage often contains harmful pathogens. Therefore, the nurse should consider this as the most probable source of the client's exposure.
Choice D rationale:
Close living quarters at evacuation centers. Rationale: Close living quarters in evacuation centers can contribute to the spread of infectious diseases, including diarrheal illnesses. However, in this scenario, the client's chief complaint is diarrhea, and the nurse should prioritize investigating potential sources of waterborne contamination, as this aligns more closely with the client's symptoms.
Correct Answer is ["B","D","E","F"]
Explanation
Choice A rationale:
Increased temperature alone is not a sufficient indication for pain medication in a post-pyloromyotomy infant. Fever can have various causes, and pain should be assessed based on other factors.
Choice B rationale:
Increased pulse rate can be an indication of pain in an infant following surgery like pyloromyotomy. It's important to assess the overall clinical picture and consider pain management if other signs are present.
Choice C rationale:
Increased respiratory rate alone is not a specific indicator of pain in a post-pyloromyotomy infant. Respiratory rate can vary for many reasons, so it should not be the sole criterion for pain management.
Choice D rationale:
Increased pulse rate is a potential sign of pain in a post-pyloromyotomy infant and should be considered when assessing the need for pain medication.
Choice E rationale:
Restlessness is often a sign of discomfort or pain in infants. Restlessness, along with other clinical indicators, can guide the decision to administer pain medication.
Choice F rationale:
Clenched fists can be a sign of discomfort or pain in infants, and it should be considered when assessing the need for pain management.
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