The nurse is watching a new nurse ventilate a client using a bag-valve mask with capnography capabilities. The nurse notices that the client's PaCO2 level is 30 mm Hg. How should the nurse interpret this finding?
The new nurse is ventilating the client too slowly.
The new nurse should prepare to assist with intubation.
The new nurse is hyperventilating the client.
The new nurse is appropriately ventilating the client.
The Correct Answer is C
A. The new nurse is ventilating the client too slowly: Slow ventilation would typically cause a rise in PaCO2 (hypercapnia), not a decrease. A PaCO2 of 30 mm Hg indicates the opposite problem.
B. The new nurse should prepare to assist with intubation: While intubation may be necessary in some situations, a PaCO2 of 30 mm Hg does not indicate imminent respiratory failure. Intubation is not indicated solely based on this capnography reading.
C. The new nurse is hyperventilating the client: A normal PaCO2 range is 35–45 mm Hg. A PaCO2 of 30 mm Hg indicates hypocapnia, most likely from excessive ventilation using the bag-valve mask. Hyperventilation can lead to respiratory alkalosis and reduced cerebral perfusion.
D. The new nurse is appropriately ventilating the client: Appropriate ventilation maintains PaCO2 within normal limits. A value of 30 mm Hg is below normal, indicating over-ventilation rather than correct technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
• Disinfecting a client's counter before administering oral medications: This practice reduces the number of microorganisms on surfaces to prevent infection, which is the principle of medical asepsis. It focuses on cleanliness and reducing contamination rather than creating a completely sterile environment.
• Covering the client and surrounding area with sterile drapes: Sterile drapes create a sterile field and prevent contamination of surgical or invasive sites. This is a key component of surgical asepsis, ensuring that instruments, supplies, and the environment remain free from microorganisms during procedures.
• Covering mouth and nose with a sleeve or elbow when coughing or sneezing: This prevents the spread of pathogens via droplets and maintains a clean environment. It is a basic principle of medical asepsis, which aims to reduce infection transmission through routine hygiene practices.
• Allowing only sterile-to-sterile contact: Maintaining a sterile field requires that sterile items only touch other sterile items. This is fundamental to surgical asepsis, preventing introduction of microorganisms during invasive procedures. Any break in sterile technique increases the risk of infection.
• Using sterile packaging for instruments and supplies: Sterile packaging preserves sterility until use, which is critical for surgical asepsis. It ensures that instruments and supplies remain free from microorganisms until the moment of use in invasive procedures.
• Using an autoclave to sterilize surgical instruments: Autoclaving uses high-pressure steam to destroy all microorganisms, achieving complete sterility. This process is a core component of surgical asepsis, making instruments safe for invasive procedures.
Correct Answer is ["A","B","C"]
Explanation
A. Sudden decrease in consciousness: An acute change in mental status may indicate hypoxia, infection, neurological injury, or other life-threatening conditions. Prompt evaluation and intervention are required.
B. Temperature of 102.1 F (38.9 C): Fever indicates a possible infection or inflammatory process, which requires further assessment and monitoring. High temperature may signal systemic involvement.
C. Pulse oximetry of 88% on room air: Oxygen saturation below 90% reflects hypoxemia and impaired gas exchange. This is an immediate concern and may require supplemental oxygen or urgent intervention.
D. Blood pressure 114/66 mmHg: This blood pressure reading is within normal limits for most adults and does not indicate immediate concern.
E. Respiratory rate of 12 per minute: A respiratory rate of 12 breaths per minute is within the normal adult range (12–20) and does not suggest respiratory compromise.
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