Your client has just returned from surgery for removal of an abdominal tumor. The postoperative arterial blood gas values are
pH 7.34
PaCO2 53 mmHg
HCO3 25 mEq/L
PaO2 70 mmHg
SaO2 91%
The nurse should
obtain a medical order for the administration of sodium bicarbonate.
prepare for intubation.
encourage the client to cough productively and take deep breaths.
have the client breathe into a rebreather bag at a slow rate.
The Correct Answer is C
A. Obtain a medical order for the administration of sodium bicarbonate: Sodium bicarbonate is used to treat metabolic acidosis, not respiratory acidosis. In this case, the elevated PaCO₂ indicates hypoventilation and respiratory acidosis, so bicarbonate would not address the underlying problem and could worsen acid-base imbalance.
B. Prepare for intubation: Intubation may be necessary if the client cannot maintain adequate ventilation or oxygenation. However, this client is showing mild respiratory acidosis with only slightly decreased oxygenation, and less invasive interventions like deep breathing and coughing should be attempted first.
C. Encourage the client to cough productively and take deep breaths: Postoperative clients often have shallow respirations due to pain, leading to hypoventilation and CO₂ retention. Encouraging deep breathing and effective coughing helps expand the lungs, improve alveolar ventilation, and reduce PaCO₂, addressing the underlying cause of the respiratory acidosis.
D. Have the client breathe into a rebreather bag at a slow rate: Rebreathing into a bag increases CO₂ levels and would worsen respiratory acidosis. This intervention is inappropriate for a client already retaining CO₂ and could further compromise acid-base balance and oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Sinus bradycardia, B/P 108/60: Sinus bradycardia with stable blood pressure and no signs of poor perfusion is usually not an emergency. While it may require monitoring and possible medication adjustments, immediate pacing is not indicated unless the client becomes symptomatic with hypotension, syncope, or chest pain.
B. Complete heart block at a rate of 30 beats per minute B/P 60/40: Complete heart block with severe bradycardia and hypotension represents a life-threatening condition. The heart is unable to maintain adequate cardiac output, leading to shock and potential cardiac arrest. Emergency pacing is indicated to restore effective heart rate and perfusion, making this the highest priority.
C. Ventricular tachycardia, B/P 50/30: Ventricular tachycardia with hypotension is a medical emergency that may require immediate defibrillation or antiarrhythmic therapy, but it is not treated primarily with a pacemaker. Pacemakers are ineffective in terminating ventricular tachyarrhythmias, so other interventions take precedence.
D. Paroxysmal atrial tachycardia B/P 70/40: While this rhythm can cause hypotension, it is usually less immediately life-threatening than complete heart block with severe bradycardia. Treatment focuses on rate control, antiarrhythmic medications, or vagal maneuvers rather than emergency pacing unless bradycardia develops after treatment.
Correct Answer is A
Explanation
A. Increases the cardiac workload: Shivering significantly increases metabolic demand and oxygen consumption, which in turn raises heart rate and blood pressure. After coronary artery bypass graft surgery, the heart is vulnerable, and increased workload can precipitate ischemia or other cardiac complications, making slow rewarming essential.
B. Increases the amount of oxygen available to the heart: Shivering does not increase oxygen availability; in fact, it increases oxygen consumption by skeletal muscles, which can reduce the oxygen supply available to the myocardium.
C. Is uncomfortable to the client: While shivering is uncomfortable, the primary concern post-CABG is the physiological stress it places on the heart, not just discomfort.
D. Promotes diuresis and volume depletion: Shivering does not directly cause significant diuresis or volume depletion. The main risk is increased myocardial oxygen demand rather than fluid loss.
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