Medical Surgical ABGs & Acid Base Imbalances #3

Question

A nurse is caring for a nulligravida preoperative C-section client who reports tingling of the fingers. Lab studies reveal pH 7.46, PCO2 31. Which action by the nurse is most appropriate?

Answers

  1. Administer oxygen and reposition the client in the semi-Fowler's position.
    • Rationale:

      This answer is not correct because oxygen is not indicated at this time due to the symptoms and lab evidence that the client is requiring CO2 instead. This intervention would be best for the client in respiratory acidosis.

  2. Instruct the client to deep breath and cough, and utilize incentive spirometry.
    • Rationale:

      This answer is not correct because this is an intervention used for a client who is at risk for ineffective airway clearance. The labs and symptoms from this client demonstrate minimal respiratory alkalosis as a result of anxiety.

  3. Plan rest periods to maximize client's energy, along with appropriate activities
    • Rationale:

      This answer is not correct since maximizing the client’s energy is not necessary at this time. This would be more relevant for the client experiencing impaired ventilation from metabolic factors or respiratory muscle fatigue.

  4. Provide a paper bag to rebreathe into for the client, as well as reassurance.
    • Rationale:

      This answer is correct because by rebreathing into a paper bag, the client is breathing in exhaled CO2, which the body requires as evidenced by her symptoms and lab work. This action is most favorable since the pH is only minimally increased and the PaCO2 is only minimally decreased. Providing reassurance and emotional support can put the client at ease about her surgery.

Overview

The lab studies reveal only slight differentiation of the acid-base values pointing to respiratory alkalosis. Coupled with the client’s symptoms, this indicates the client is experiencing anxiety. Giving reassurance to the client will help emotionally, and providing a paper bag for ventilation will help physically.

Explanation

Learning Outcomes

A pH higher than 7.45 and a PCO2 lower than 32 indicates respiratory alkalosis. The symptoms of fingers tingling and the fact that the client will be giving birth via Cesarean section for the very first time indicates the client may be feeling anxious. The lab studies reveal only slight differentiation of the acid-base values. Having the client rebreathe into a paper bag can provide the client with CO2 that the body is lacking. Providing emotional support and reassurance may relieve the client’s anxiety and slow her breathing down. Administering oxygen is indicated in respiratory acidosis. Deep breathing and coughing is an intervention used for ineffective air clearance. Maximizing the client’s energy is not necessary at this time.

Test Taking Tip

Taking note that the client is “nulligravida”, no prior pregnancies or births, and she is preoperative for a C-section clues the student that the client may be experiencing anxiety. Also, pregnancy can stimulate the respiratory center due to the increased levels of progesterone. Thus, respiratory alkalosis is a common finding in pregnant women.

Video Rationale