The nurse is caring for a patient that has had an acute myocardial infarction. What goals should the nurse use to guide this patient's care? (SELECT ALL THAT APPLY).

A. Respiratory rate 26, irregular: Pt reports no shortness of breath or chills: An irregular respiratory rate may indicate some underlying issues. Although the patient reports no shortness of breath or chills, an irregular respiratory rate could signal a cardiac issue or a lingering effect of the infection. It’s not sufficient to confirm the effectiveness of antibiotic therapy.

B. Temp-99F (37.2°C); Lungs clear bilaterally; Pulse ox 98% on 2 liters oxygen; productive cough: clear to yellow sputum: This indicates improvement in the patient’s condition:

A temperature of 99°F is a mild, controlled fever, which is common in the recovery phase but suggests a reduction from higher fever associated with infection.

Clear lungs bilaterally are a good sign, indicating that there is no longer significant consolidation or inflammation in the lungs.

Pulse oximetry of 98% on 2 liters of oxygen is a positive sign that the oxygenation is improving.

Productive cough with yellow sputum indicates that the body is still clearing the infection, but it is a typical sign of recovery as the patient produces sputum.

C. Pt reports fatigue: Resp rate 28 on 2 liters oxygen: audible expiratory wheezes: This is concerning. The patient is still experiencing fatigue and audible wheezes, which may indicate unresolved inflammation or bronchoconstriction. The respiratory rate of 28, while slightly elevated, also suggests ongoing respiratory stress. This could indicate that the infection is not fully controlled.

D. Cough: white sputum: Temp 99F (37.2°C); Pulse ox 96%: This is somewhat positive, but it lacks the detail of clear lungs or other more definitive signs of improvement. The white sputum could suggest that the infection is resolving, but there is still some degree of infection or inflammation. Pulse ox at 96% is acceptable, but the lack of clear lungs bilaterally makes it less ideal.

A. pH 7.47, pCO2 30, HCO3 24, pO2 98

pH is alkaline (7.47), and the pCO2 is low (30), indicating respiratory alkalosis, not acidosis. This is not the correct answer.

B. pH 7.31, pCO2 52, HCO3 30, pO2 85

pH is low (7.31), indicating acidosis.

pCO2 is elevated (52), indicating respiratory acidosis.

HCO3 is elevated (30), indicating that the kidneys are attempting to compensate by retaining bicarbonate.

This fits the criteria for respiratory acidosis with partial compensation.

C. pH 7.29, pCO2 57, HCO3 25, pO2 78

pH is low (7.29), indicating acidosis.

pCO2 is elevated (57), suggesting respiratory acidosis.

HCO3 is normal (25), so there is no compensation yet.

This indicates uncompensated respiratory acidosis, not partial compensation.

D. pH 7.37, pCO2 61, HCO3 33, pO2 71

pH is normal (7.37), which does not indicate acidosis.

pCO2 is elevated (61), indicating respiratory acidosis.

HCO3 is elevated (33), indicating that the kidneys are compensating.

However, since the pH is normal, this likely indicates full compensation rather than partial compensation.