The nurse is developing a plan of care for a client admitted with hypoxemia related to altered alveolar diffusion. When formulating a plan of care the nurse is aware which intervention must be included?

Providing pain management to adhere to coughing and deep breathing exercises

Teaching the client to use the tripod position

Adding humidity with supplemental oxygen to keep secretions thin

Supplying additional oxygen while the client is at rest

Answer and Explanation

The Correct Answer is C

A. Providing pain management to adhere to coughing and deep breathing exercises: While pain management is important for overall comfort and encouraging deep breathing and coughing, it is not the primary intervention for managing hypoxemia due to altered alveolar diffusion. The key intervention for hypoxemia from impaired alveolar diffusion focuses more on improving oxygenation and addressing the underlying cause.

B. Teaching the client to use the tripod position: The tripod position, which involves sitting upright and leaning forward with hands on knees, can help improve breathing for patients with certain respiratory conditions (e.g., COPD), but it is not directly related to the management of hypoxemia caused by altered alveolar diffusion.

C. Adding humidity with supplemental oxygen to keep secretions thin: Hypoxemia related to altered alveolar diffusion often results from difficulty in gas exchange due to thickened secretions or inflammation. Adding humidity to supplemental oxygen helps thin the secretions, making it easier to clear them, and can improve gas exchange in the lungs, which directly helps address the hypoxemia.

D. Supplying additional oxygen while the client is at rest: While providing supplemental oxygen to maintain adequate oxygen levels is important in managing hypoxemia, this option does not specifically address the issue of altered alveolar diffusion. Humidified oxygen can be more beneficial in improving secretion clearance and promoting better diffusion in such cases.

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Correct Answer is C

Explanation

A. The ABG results are pH 7.41, PaO2 93, PaCO2 35, and HCO3 24: These ABG values are all within normal ranges:
pH 7.35–7.45 (normal)
PaO2 80–100 mmHg (normal)
PaCO2 35–45 mmHg (normal)
HCO3 22–26 mEq/L (normal)
These results indicate stable respiratory function and do not warrant immediate intervention.
B. The client's pulse oximeter reading is 91% with a consistent waveform: While 91% is slightly lower than the ideal oxygen saturation (usually above 92%–94%), it is still above the critical threshold of 90%. This could be an acceptable level in some patients on a ventilator, particularly if there are no signs of distress or other abnormalities.
C. There is no manual resuscitation bag at the client's bedside: This is a critical situation. A manual resuscitation bag (Ambu bag) is essential for emergency resuscitation if the ventilator fails or if there is an unexpected issue with the patient's airway. Not having a manual resuscitation bag at the bedside is a safety concern that warrants immediate intervention, as it could delay life-saving measures in an emergency.
D. The patient is receiving continuous IV sedation at 150 mL/hr. There's currently 100 mL remaining of the infusion: While it's important to monitor IV sedation infusions, this situation does not immediately warrant intervention. The nurse can track the remaining infusion and ensure there is an adequate supply or order a new infusion if necessary.

A. Insert an oral airway to prevent the client from biting the endotracheal tube B. Suction the patient and reset the ventilator alarm C. Disconnect the client from the ventilator and use a manual bag-valve mask D. Notify the respiratory therapist and health care provider

Correct Answer is C

Explanation

A. Inserting an oral airway may be appropriate if the client is biting the endotracheal tube, but in this scenario, the cause of the low-pressure alarm is unknown and could be due to disconnection or a leak — a more urgent issue requiring immediate action.
B. Suctioning and resetting the alarm could delay appropriate ventilation if the issue is a disconnection or leak; it’s not the priority intervention in an unclear emergency.
C. When the source of a low-pressure alarm (which often indicates a leak or disconnection) cannot be identified and the client’s ventilation status is in question, the nurse should immediately disconnect the client from the ventilator and manually ventilate with a bag-valve mask to ensure oxygenation until the issue is resolved.
D. Notifying the respiratory therapist and provider is appropriate after immediate interventions are performed to maintain the patient’s airway and oxygenation.

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The nurse is developing a plan of care for a client admitted with hypoxemia related to altered alveolar diffusion. When formulating a plan of care the nurse is aware which intervention must be included?

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Naxlex Comprehensive Predictor Exams

A patient is on a ventilator. Which situation warrants immediate intervention by the nurse? ABG pH 7.35-7.45 pa02 80-100 mg Hg PC02 35-45 mm Hg PHCO3 22-26meQ/L

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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