A nurse is reviewing the ABG results of a client who has COPD. The results include a pH of 7.3 (7.35 to 7.45), PaO2 56 mm Hg (80 to 100 mm Hg), PaCO2 54 mm Hg (35 to 45 mm Hg), HCO3- 26 mEq/L (21 to 28 mEq/L), and SaO2 87%. Which of the following is the correct interpretation of these values?
Compensated metabolic acidosis
Compensated respiratory acidosis
Uncompensated respiratory acidosis
Uncompensated metabolic acidosis
The Correct Answer is C
Rationale:
A. Compensated metabolic acidosis would show a normal pH with a decrease in HCO3- and a decrease in PaCO2.
B. Compensated respiratory acidosis would show a normal pH with an elevated PaCO2 and a compensatory increase in HCO3-.
C. The low pH indicates acidosis, and the elevated PaCO2 suggests that it is respiratory in origin, with the HCO3- remaining normal, indicating no compensation has occurred yet.
D. Uncompensated metabolic acidosis would present with a low pH, low HCO3-, and normal PaCO2.
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Correct Answer is A
Explanation
Rationale:
A. This response validates the client's feelings and opens the door for further conversation without judgment, encouraging the client to express more of their thoughts.
B. While this statement acknowledges the client's feelings, it may seem dismissive or minimize the depth of the client's distress.
C. Telling the client that many people experience similar feelings can invalidate the uniqueness of their grief and may discourage them from sharing more.
D. Asking "Why" may sound accusatory and could make the client feel defensive or misunderstood.
Correct Answer is A
Explanation
Rationale:
A. Assessing the client's IV site every 8 hours is appropriate to prevent complications such as infection or infiltration, especially in an immunocompromised client.
B. Checking the client's WBC count every 48 hours is insufficient; it should be monitored more frequently due to the client's immunocompromised state.
C. Monitoring the client's mouth every 8 hours is necessary, but not as critical as regular IV site assessments.
D. Changing the client's tubing every 48 hours may not be necessary unless indicated by the facility's protocol or the client's condition; continuous IV tubing is typically changed every 72 to 96 hours unless there are signs of complications.