A client has the following arterial blood gases: pH 7.30, HCO3– 17 mEq/L, PCO2 25 mm Hg, PO2 98 mm Hg. Which intervention by the nurse is most appropriate?
a. Prepare to give intravenous sodium bicarbonate.
b. Document the findings and continue to assess.
c. Assist the physician in determining the cause.
d. Administer oxygen at 2 L per nasal cannula.
C
The client has a partially compensated metabolic acidosis. Interventions are aimed at reducing or eliminating the cause. The nurse needs to assist in determining the cause so that proper interventions can be initiated. Sodium bicarbonate is rarely used for acidosis unless the pH is life threatening, or for specific causes of acidosis wherein bicarbonate deficit is known to be the problem. Simply documenting the findings will not help the client. Because the client's PO2 is 98 mm Hg, oxygen therapy is not indicated on the basis of these arterial blood gases.
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To document absent bowel sounds correctly, one must listen continuously for:
a. 30 seconds. b. 1 minute. c. 3 minutes. d. 5 minutes.
It is very important that nurses work closely with families in addressing health needs. Reasons for this include each of the following except
1. A clear understanding of the functioning of the individual can be gained only when the individual is assessed within the larger context of the family. 2. Commonalities in risk factors and disease shared by family members can lead to case finding within the family. 3. Family wellness is highly dependent on the role of the family in health care and can be raised through reducing lifestyle and environmental risks and emphasizing health promotion, self-care, health education, and family counseling. 4. It is important to detect nontraditional families that are considered to be at risk for dysfunction. 5. Within the family unit, any dysfunction that affects one or more family members will affect the family as a whole.