The nurse receives the following ABG result. pH = 7.00 PaCO2 = 50 mm Hg PaO2 = 89 mm Hg SaO2 = 90% Based on the results, what would the nurse expect to do first?
1. Check the last dose of CNS depressant drug.
2. Assess lung sounds and vital signs.
3. Review the history for asthma or emphysema.
4. Apply oxygen per nasal cannula at 2 L/min.
2
Rationale 1: This can be done after the patient assessment is done.
Rationale 2: Assess lung sounds and vital signs because patient assessment is always performed first before actions are implemented. Both the pH and PaCO2 reflect respiratory acidosis caused by decreased respiratory effectiveness. Changes in breath sounds and vital signs can identify respiratory acidosis.
Rationale 3: This can be done some other time.
Rationale 4: Further assessment is needed before this is implemented.
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After describing the Multimedia Educational Resource for Learning and Online Teaching (MERLOT) site as an excellent source for learning resources,
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