The nurse is caring for a client diagnosed with respiratory acidosis, and directs the plan of care to provide which of these priority interventions?
1. Increase fluid intake.
2. Have the client breathe into a paper bag.
3. Administer oxygen.
4. Encourage the client to take deep breaths.
4
Rationale: Respiratory acidosis is caused by inadequate gas exchange, and would best be treated by having the client take deeper breaths to blow off excess carbon dioxide. Oxygen will increase pO2 levels but will not reduce carbon dioxide levels. Increased fluid intake would be appropriate for metabolic acidosis, but will have no affect on respiratory acidosis. A paper bag would be helpful to reverse respiratory alkalosis but will worsen respiratory acidosis.
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When other methods have failed to stop the bleeding and the victim's life is in danger, the rescuer at the scene applies a tourniquet to a young woman's leg above the knee. It is essential that the rescuer:
a. never release the tourniquet. b. wrap the tourniquet around the limb twice. c. mark the patient with a "T." d. leave the limb elevated.
On what day should an outing to the park for a group of older adults be canceled?
a. 75-degree sunny day in Texas b. 70-degree cloudy day in Oregon c. 80-degree sunny day in Florida d. 75-degree ozone alert day in California
The nurse is assessing the pain of an 86-year-old man who is recovering from a right hip open reduction procedure. What element would the nurse know it is important to review to best understand the patient's pain?
A) Sleep patterns B) Family history C) Genetic history D) Elimination pattern
An appropriate, realistic short-term goal for a client with beginning stages of Alzheimer's disease who is being admitted to an assisted living facility includes:
1. Client will not wander about the facility. 2. Client will maintain a normal weight. 3. Client will be able to verbalize feelings of anger, fear, and trust, when appropriate. 4. Client will be oriented to the surroundings.