Your septic client is becoming restless and tachypneic. His arterial blood gases show pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L; PaO2 76 mmHg; SaO2 90%. You would interpret these ABG findings as consistent with

normal ABG results.

early acute respiratory distress syndrome.

acute ventilatory failure.

late acute respiratory distress syndrome.

Answer and Explanation

The Correct Answer is B

A. Normal ABG results: The ABG shows a pH of 7.50 (alkalemia) and PaCO₂ of 30 mmHg (hypocapnia), indicating respiratory alkalosis, which is not normal. PaO₂ is slightly low at 76 mmHg, and SaO₂ is decreased at 90%, further confirming abnormal gas exchange.

B. Early acute respiratory distress syndrome: Early ARDS is characterized by hypoxemia (PaO₂ < 80 mmHg) and respiratory alkalosis caused by hyperventilation as the patient compensates for impaired oxygenation. Restlessness and tachypnea are also typical early clinical signs. These ABG findings align with the early compensatory phase of ARDS.

C. Acute ventilatory failure: Acute ventilatory failure usually presents with respiratory acidosis (elevated PaCO₂) and hypoxemia, indicating insufficient ventilation. This client has low PaCO₂, which indicates hyperventilation rather than ventilatory failure.

D. Late acute respiratory distress syndrome: Late ARDS is marked by worsening hypoxemia, hypercapnia, and respiratory acidosis due to alveolar collapse and decreased lung compliance. This client’s ABG shows alkalosis and mild hypoxemia, consistent with early, not late, ARDS.

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Correct Answer is B

Explanation

A. Staying with the client during the first 15 minutes of the transfusion: Close monitoring during the initial phase allows the nurse to detect early signs of a reaction, such as fever, chills, or hypotension. While essential for safety, this action does not prevent a reaction from occurring; it only facilitates rapid recognition and intervention.

B. Properly identifying the client: Accurate client identification is the most critical step in preventing transfusion reactions because it ensures that the correct blood product is given to the intended recipient. Mismatched blood can cause life-threatening hemolytic reactions, making verification of identity and blood type a primary preventive measure.

C. Warming the blood during administration: Warming blood is sometimes indicated to prevent hypothermia in clients receiving large or rapid transfusions, but it does not prevent immunologic transfusion reactions. This action addresses thermal safety rather than compatibility-related complications.

D. Administering the blood at a rate of no more than 2 mL/minute: Administering blood slowly at the start of a transfusion allows early detection of adverse reactions, but it does not prevent the reaction itself. Rate control is a monitoring strategy rather than a preventive action against mismatched or incompatible transfusions.

A. Increase the rate and/or tidal volume B. Increase the PEEP C. Sedate and paralyze the client D. Increase the FiO2 and/or PEEP

Correct Answer is A

Explanation

A. Increase the rate and/or tidal volume: Respiratory acidosis occurs when CO₂ retention results from hypoventilation. Adjusting the ventilator to increase the respiratory rate or tidal volume enhances alveolar ventilation, helping to remove CO₂ and correct the acidosis. This intervention directly targets the underlying cause of the abnormal ABG.

B. Increase the PEEP: Positive end-expiratory pressure helps keep alveoli open and improve oxygenation but does not directly increase CO₂ elimination. While beneficial for hypoxemia, adjusting PEEP alone will not correct respiratory acidosis caused by hypoventilation.

C. Sedate and paralyze the client: Sedation and paralysis may be used to facilitate ventilator synchrony in specific situations, but they do not directly correct CO₂ retention. These interventions are not the first-line approach for managing respiratory acidosis and could worsen hypoventilation if not carefully managed.

D. Increase the FiO2 and/or PEEP: Increasing FiO₂ and PEEP improves oxygenation but does not enhance CO₂ removal. Respiratory acidosis requires interventions that increase alveolar ventilation rather than just oxygen delivery.

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Your septic client is becoming restless and tachypneic. His arterial blood gases show pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L; PaO2 76 mmHg; SaO2 90%. You would interpret these ABG findings as consistent with

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Naxlex Comprehensive Predictor Exams

Which nursing action is most important in prevention of transfusion reactions?

Correct Answer is B

Explanation

On an intubated client which of the following interventions would potentially correct ABG results indicating respiratory acidosis?

Correct Answer is A

Explanation

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