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?

The correct answer is choice d. Verify that Client B has two units of packed cells available.

Choice A rationale:

Moving Client D into an isolation room 24 hours before surgery is not necessary solely based on an elevated WBC count. Elevated WBCs indicate infection or inflammation, but isolation is not typically required unless there is a contagious infection.

Choice B rationale:

Client C’s potassium level of 3.8 mEq/L is within the normal range (3.5 to 5.0 mEq/L). Adding a banana, which is high in potassium, is not necessary.

Choice C rationale:

Client A with emphysema and an oxygen saturation of 94% does not require an increase in oxygen. Oxygen therapy should be carefully managed in clients with emphysema to avoid suppressing their respiratory drive.

Choice D rationale:

Client B has a postoperative hemoglobin of 8.2 mg/dL, which is significantly below the normal range (14 to 18 g/dL). This client may require a blood transfusion to address the low hemoglobin level, making it essential to verify the availability of packed red blood cells.

Choice A rationale:

Monitoring blood pressure is a general health assessment measure and may not directly contribute to pain relief in a client with migraine headaches. While it's essential to manage blood pressure as part of overall health, this choice does not address the client's specific request for pain relief.

Choice B rationale:

Taking a few days off work may provide some relief from external stressors, but it is not a reliable intervention for migraine pain relief. Migraine management typically involves strategies that directly target headache symptoms.

Choice C rationale:

Learning muscle relaxation techniques can be helpful in managing migraine headaches. Relaxation techniques, such as progressive muscle relaxation, can reduce muscle tension and help alleviate headache symptoms. However, it may not be the highest-priority intervention.

Choice D rationale:

Lying down in a dark, quiet room is the most appropriate intervention for obtaining pain relief from a migraine headache. This approach minimizes sensory stimuli, reduces external factors that may exacerbate the headache, and promotes relaxation. It is a well-established non-pharmaceutical method for managing migraine pain.