A patient with a lower respiratory infection has pH of 7.25, PaCO2 of 55 mm Hg, and HCO3– of 20 mEq/L. The physician has been notified. Which is the priority nursing intervention for this patient?
a. Check the color of the patient's urine output.
b. Place the patient in Trendelenburg position.
c. Encourage the patient to increase respirations.
d. Place the patient in high Fowler's position.
C
The patient has respiratory acidosis from CO2 retention. Increasing rate and depth of respiration will allow the patient to blow off excess carbon dioxide, and this will begin to correct the imbalance. Checking the urine color is not a necessary assessment. The Trendelenburg position likely would make it more difficult for the patient to breathe and should be avoided. Placing the patient in high Fowler's position may make the patient more comfortable, but it is not necessary.
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A 15-year-old girl is being admitted to an inpatient mental health clinic with the diagnosis of anorexia nervosa. The nurse knows that the most common personality characteristic of teens affected with this disorder is:
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A nurse is trying to discover what would be the best standard of care for a client with preterm labor. To find the most definitive information about this topic, the nurse should look to which of the following sources?
1. state Nurse Practice Act 2. employee job description 3. job orientation checklist 4. specialty nursing organization literature