The nurse receives report that a client's pH level is 7.4. Which nursing action would be most appropriate?

Encourage the client to practice deep breathing.

Call the health care provider with the report.

Obtain an ECG.

Finish the head-to-toe assessment.

Answer and Explanation

The Correct Answer is D

A. Encourage the client to practice deep breathing: Deep breathing may be helpful in correcting respiratory acidosis or alkalosis, but it is not needed when the pH is normal. The client’s acid-base balance does not require intervention at this time.
B. Call the health care provider with the report: A pH of 7.4 is within the normal range (7.35–7.45). Reporting a normal pH value in isolation is generally not necessary unless it's part of a trend or if the clinical picture suggests otherwise. The nurse should complete their assessment and consider all findings before contacting the provider.
C. Obtain an ECG: An ECG may be warranted if there are signs of electrolyte imbalances or cardiac symptoms. However, a normal pH level alone does not justify performing an ECG in the absence of additional findings.
D. Finish the head-to-toe assessment: With a normal pH level, the nurse should continue routine care, including completing the assessment. No urgent intervention is required, making this the most appropriate next step.

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Correct Answer is A

Explanation

A. Alveoli: The alveoli are responsible for gas exchange, including the removal of CO₂. Impaired alveolar function leads to CO₂ retention and respiratory acidosis, commonly seen in conditions like COPD or pneumonia.
B. The pulmonary artery: The pulmonary artery carries deoxygenated blood to the lungs but does not directly participate in gas exchange. Impairment here affects perfusion, not CO₂ elimination.
C. The pulmonary vein: The pulmonary vein returns oxygenated blood to the heart and is not involved in gas exchange. Elevated CO₂ is not typically linked to vein function.
D. Bronchi: The bronchi conduct air but do not facilitate gas exchange. While obstruction can contribute to CO₂ retention, the alveoli are primarily responsible for its removal.

A. Metabolic acidosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic alkalosis

Correct Answer is D

Explanation

A. Metabolic acidosis: This condition typically results from excessive acid accumulation or bicarbonate loss, such as in kidney failure or diarrhea. It is not associated with gastric fluid loss via suction.
B. Respiratory acidosis: Respiratory acidosis is caused by hypoventilation leading to CO₂ retention. It is unrelated to nasogastric suction and does not reflect the primary concern for this client.
C. Respiratory alkalosis: This occurs due to hyperventilation and excessive loss of CO₂, often from anxiety or pain. It is not a risk in a client with GI fluid loss from suction.
D. Metabolic alkalosis: Nasogastric suction removes hydrochloric acid from the stomach, leading to a loss of hydrogen ions. This results in an increased bicarbonate concentration, predisposing the client to metabolic alkalosis.

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The nurse receives report that a client's pH level is 7.4. Which nursing action would be most appropriate?

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Naxlex Comprehensive Predictor Exams

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