A new nurse graduate is caring for a postoperative...

HESI RN MEDICAL SURGICAL EXAM PACK QUESTIONS AND ANSWERS

Question Number 12

A new nurse graduate is caring for a postoperative client with the following arterial blood gases (ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%. Which of these actions by the new graduate is indicated?A) Encourage the client to use the incentive spirometer and to cough.B) Administer oxygen by nasal cannula.C) Request a prescription for sodium bicarbonate from the health care provider.D) Inform the charge nurse that no changes in therapy are needed.

A) Encourage the client to use the incentive spirometer and to cough.Rationale: Respiratory acidosis is caused by CO2 retention and impaired chest expansion secondary to anesthesia. The nurse takes steps to promote CO2 elimination, including maintaining a patent airway and expanding the lungs through breathing techniques. O2 is not indicated because Po2 and oxygen saturation are within the normal range. Sodium bicarbonate is not indicated because the bicarbonate level is in the normal range; promoting excretion of respiratory acids is the priority in respiratory acidosis. Post anesthesia, the client will need interventions as described in A above or may progress to a state of somnolence and unresponsiveness.

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HESI RN MEDICAL SURGICAL EXAM PACK QUESTIONS AND ANSWERS

Question Number 12

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