A nurse evaluates the following arterial blood gas and vital sign ...

[chads108]

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD):
 
  Arterial Blood Gas Results
  Vital Signs
  pH = 7.32
  PaCO2 = 62 mm Hg
  PaO2 = 46 mm Hg
  HCO3- = 28 mEq/L
  Heart rate = 110 beats/min
  Respiratory rate = 12 breaths/min
  Blood pressure = 145/65 mm Hg
  Oxygen saturation = 76
  Which action should the nurse take first?
  a.
  Administer a short-acting beta2 agonist inhaler.
  b.
  Document the findings as normal for a client with COPD.
  c.
  Teach the client diaphragmatic breathing techniques.
  d.
  Initiate oxygenation therapy to increase saturation to 92.

Question 2

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)
 
  a. Administer prescribed salmeterol (Serevent) inhaler.
  b. Assess the client for a tracheal deviation.
  c. Administer oxygen to keep saturations greater than 94.
  d. Perform peak expiratory flow readings.
  e. Administer prescribed albuterol (Proventil) inhaler.

[cpetit11]

Answer to Question 1

ANS: D
Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the client's hypoxia, which is the priority.

Answer to Question 2

ANS: C, E
Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding.

[chads108]

Excellent

[xiaomengxian]

TYSM