Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement?
A. Instructing the client to breathe slowly into a paper bag.
B. Administering low-flow oxygen.
C. Encouraging the client to cough and deep breathe.
D. Nothing, because these ABG values are within normal limits.
Correct Answer: C. Encouraging the client to cough and deep breathe.
The ABG results indicate respiratory acidosis requiring improved ventilation and increased oxygen to the lungs. Coughing and deep breathing can accomplish this. Encourage and assist with deep-breathing exercises, turning, and coughing. Suction as necessary. Provide airway adjunct as indicated. Place in semi-Fowler’s position. These measures improve lung ventilation and reduce or prevent airway obstruction associated with the accumulation of mucus.
Option A: Breathing into a paper bag is appropriate for a client hyperventilating and experiencing respiratory alkalosis. Provide appropriate chest physiotherapy, including postural drainage and breathing exercises. Aids in clearing secretions, which improves ventilation, allowing excess CO2 to be eliminated.
Option B: The nurse would administer high oxygen levels because the client does not have chronic obstructive pulmonary disease. Administer oxygen as indicated. Increase respiratory rate or tidal volume of the ventilator, if used. Prevents and corrects hypoxemia and respiratory failure.
Option D: Some action is necessary because the ABG results are not within normal limits. Monitor and graph serial ABGs, pulse oximetry readings; Hb, serum electrolyte levels. Evaluates therapy need and effectiveness. Note: Bedside pulse oximetry monitoring is used to show early changes in oxygenation before other signs or symptoms are observed.
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