Electrolytes Question #20

Question

A client with pneumonia has an arterial blood gas (ABG) of pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45. Which action should the nurse take?

Answers

  1. Administer a sedative
    • Rationale:
  2. Place client in left lateral position
    • Rationale:
  3. Place client in high-Fowler's position
    • Rationale:
  4. Assist the client to breathe into a paper bag
    • Rationale:

Overview

Explanation

The correct answer is C. The ABG of pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45 indicates respiratory acidosis. Placing the client in high-Fowler’s position will facilitate the expansion of the lungs and help the client blow off the excess CO2. Sedatives would impede respirations. The question does not indicate which is the affected lung, so left lateral position would not be a first choice. Breathing into a paper bag will cause the PCO2 to increase further.

NCLEX TIP: Using critical thinking is recommended when reading priority questions. Recognizing key words in the answer choices will allow you to know how to choose the correct answer for the question. Go through each answer choice and decide is it: Maslow’s hierarchy, safety-related, or following the nursing process (ADPIE). Never complete a nursing action that is outside the scope of practice.

Learning Outcomes

Test Taking Tip

Video Rationale