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 ["B","C","D"]
Explanation
Rationale:
A. Assessing a client requires clinical judgment and should not be delegated to an AP.
B. Accompanying a client to occupational therapy is a task that can be safely assigned to an AP as it does not require clinical judgment.
C. Checking the position of a client in soft wrist restraints is a routine task that can be assigned to an AP as long as the AP has been trained in restraint protocols.
D. Sitting with a client who has alcohol use disorder (5 days after their last drink) is a task that an AP can perform, especially if the client does not require close monitoring for medical complications such as delirium tremens.
E. Setting limits with a client requires therapeutic communication skills and clinical judgment, so this should not be delegated to an AP.
Correct Answer is C
Explanation
Rationale:
A. Selecting a quiet location is important, but first, it is essential to assess the client's current state and the surrounding environment.
B. Providing options can help empower the client, but it is best to first observe the client to gauge their level of agitation and determine the appropriate response.
C. Observing the client and the situation allows the nurse to understand the severity of the agitation and the context, which is critical for making informed decisions about the next steps.
D. Respecting personal space is important, but it should follow an assessment of the situation to ensure safety for both the client and staff.