Difficulty: Medium
Average Score: 89%
Simulated
Passage / Scenario
Nurse's Notes: Client admitted to the unit 12 hr ago with pneumonia, over the last 1 hr the client has exhibited dyspnea and restlessness. Respiratory rate is currently 32/min with deep breaths, BP 198/78 mm Hg. Oxygen has been increased from 2 L nasal cannula to 50% face mask with little improvement of oxygen saturation. Current oxygen saturation is 91% on 50% facemask. Arterial blood gases drawn and sent to lab. Diagnostic Results: ABGS: pH 7.25 (7.35 to 7.45), pCO2 62 mm Hg (35 to 45 mm Hg), HCO3-22 mEq/L (22 to 26 mEq/L).A nurse is caring for a client who has pneumonia on a medical-surgical unit. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Correct answer
B
Rationale
The client's low pH and high pCO2 indicate respiratory acidosis. Preparing for intubation and administering a bronchodilator address respiratory distress, while monitoring arterial blood gases and ETT placement ensures effective treatment.