The nurse is caring for a client who was admitted in respiratory distress. Which is the nurse's priority action based on the data obtained from this ABG:
pH: 7.32
PaCO2: 52
PaO2: 94
HCO3: 20
1. Place the client on O2 via mask.
2. Document and continue to monitor.
3. Call the healthcare provider to report the results.
4. Suction the client using a Yankeur.
Place the client on O2 via mask.
Rationale: In blood gases, normal pH: 7.35−7.45; normal PaCO2: 34−45 mmHg; normal PaO2: 80−100 mmHg; normal HCO3: 22−26 mEq/L; so respiratory acidosis occurs when the pH drops below 7.35, the PaCO2 is >45 mmHg, the PaO2 is normal or decreased, and the HCO3 is < 22 mmHg. Thus, this client requires oxygen. Once placed, the nurse can report the results. Suctioning is not indicated. The nurse should continue to document and monitor, but not until the patient has been placed on oxygen.
You might also like to view...
An oncology nurse is providing for an adult patient who is currently immunocompromised. The nurse is aware of the physiology involved in hematopoiesis and immune function, including the salient role of cytokines
What is the primary role of cytokines in maintaining homeostasis? A) Cytokines perform phagocytosis in response to bacterial and protozoal infection. B) Cytokines perform a regulatory role in the development of diverse blood cells. C) Cytokines can be considered to be the basic "building blocks" of all blood cells. D) Cytokines are formed in response to the presence of antibodies.
A patient is receiving chemotherapy for cancer. The nurse reviews the laboratory data and notes that he has thrombocytopenia. Which nursing diagnosis should be given the highest priority?
A) Activity intolerance B) Impaired tissue integrity C) Impaired oral mucous membranes D) Ineffective tissue perfusion (cerebral, cardiopulmonary, GI)
How should a nurse position the body after the death of a patient?
a. Prone b. Supine c. On the side d. In Fowler position
The nurse is preparing discharge instructions for a patient recovering from acute respiratory distress syndrome (ARDS). What should be included in this teaching?
: Select all that apply. 1. Avoid smoking and exposure to air pollution. 2. Practice lifestyle modifications to reduce oxygen demands. 3. Restrict fluids to prevent congestive heart failure (CHF). 4. Get the influenza immunization annually. 5. Avoid large crowds.