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 pa-tient?
a. Check the color of the patient's urine output.
b. Place the patient in Trendelenburg posi-tion.
c. Encourage the patient to increase respira-tions.
d. Place the patient in high Fowler's position.
ANS: 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 imbal-ance. 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 pa-tient in high Fowler's position may make the patient more comfortable, but it is not necessary.
You might also like to view...
A nurse should monitor a client for which of the following adverse reactions during the administration of tocolytic therapy to prevent uterine contractions? Select all that apply
A) Fatigue B) Diaphoresis C) Diplopia D) Hypertension E) Prolonged vaginal bleeding
A 46-year-old patient has been diagnosed with cancer. He has met with the oncologist and is now weighing his options to undergo chemotherapy or radiation as his treatment. This patient is utilizing which ethical principle in making his decision?
A) Beneficence B) Confidentiality C) Autonomy D) Justice
The normal term infant has little difficulty clearing its airway after birth. Most secretions are brought up to the oropharynx by the cough reflex
However, if the infant has excess secretions, the mouth and nasal passages can easily be cleared with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to a. Avoid suctioning the nares. b. Insert the compressed bulb into the center of the mouth. c. Suction the mouth first. d. Remove the bulb syringe from the crib when finished.
The nurse smells smoke and notes what appears to be a fire in the waste basket in the client's room. Which is the nurse's first action when the fire is noted?
A. Pull the fire alarm. B. Grab the closest fire extinguisher. C. Enter the client's room and immediately close the client's door. D. Assist the client out of the room.