A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?

Correct Answer: A

Rationale: The correct answer is A: Assess the airway. The nurse should prioritize airway assessment as the client's ABGs indicate respiratory acidosis (low pH, high PaCO2). This suggests potential airway obstruction or inadequate ventilation. Ensuring a patent airway is crucial for adequate oxygenation. Administering bronchodilators (B) or mucolytics (D) may help with airway clearance but should come after ensuring a clear airway. Providing oxygen (C) is important, but addressing the underlying respiratory acidosis by first assessing the airway is the priority in this situation to prevent further deterioration.

Correct Answer: A

Rationale: The correct answer is A: Assess clients rate, rhythm, and depth of respiration. The arterial blood gas values indicate a respiratory acidosis due to low pH and low PaCO2. The nurse should assess the respiratory status to determine if the client is hypoventilating, which is causing the retention of CO2 and subsequent acidosis. Assessing the rate, rhythm, and depth of respiration will help determine if the client requires immediate intervention such as oxygen therapy, mechanical ventilation, or respiratory treatment. Choice B is incorrect because measuring pulse and blood pressure does not directly address the underlying cause of the acid-base imbalance. Choice C is incorrect as the nurse should take immediate action to address the imbalance rather than passively monitoring. Choice D is incorrect as immediate intervention is needed to address the respiratory acidosis.

Correct Answer: B

Rationale: The correct answer is B: Anxiety-induced hyperventilation. The arterial blood gas values show a pH of 7.48 (alkalosis) with low PaCO2 (respiratory alkalosis), which is consistent with hyperventilation due to anxiety. HCO3 is within normal range, ruling out metabolic causes. A: Diarrhea and vomiting would lead to metabolic acidosis with low pH and decreased HCO3. C: COPD would typically present with respiratory acidosis (high PaCO2) and normal to high HCO3. D: Diabetic ketoacidosis and emphysema would show metabolic acidosis with low pH and low HCO3.

Correct Answer: D

Rationale: The correct answer is D: Increased conservation of sodium. Older adults tend to have an increased conservation of sodium, leading to fluid retention and decreased fluid intake, which can contribute to dehydration. A: Decreased kidney mass is incorrect because it is a factor that can contribute to decreased kidney function but not directly linked to dehydration. B: Decreased renal blood flow can impact kidney function but is not a direct cause of dehydration in older adults. C: Decreased excretion of potassium is not a factor that directly contributes to dehydration in older adults.

Correct Answer: D

Rationale: Rationale: Third spacing occurs when fluid shifts from the intravascular space to interstitial spaces, leading to hypovolemia. This results in decreased circulating blood volume, leading to signs of hypovolemia such as tachycardia, hypotension, and low urine output. Metabolic alkalosis, hypermagnesemia, and hypercalcemia are not directly related to third spacing and are not the expected imbalances in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Decrease in glomerular filtration. Sympathetic stimulation constricts renal arterioles, leading to decreased blood flow to the kidneys. This reduction in blood flow decreases the glomerular filtration rate, impacting the kidney's ability to filter blood and produce urine. The constriction of renal arterioles does not directly affect the release of aldosterone (choice A), filtration in the Loop of Henle (choice B), or the reabsorption of sodium (choice C). The primary effect of sympathetic stimulation on renal arterioles is to decrease glomerular filtration by reducing blood flow to the kidneys.

Correct Answer: D

Rationale: The correct answer is D: Shallow respirations. Hypermagnesemia can lead to respiratory depression due to its inhibitory effect on the central nervous system. Shallow respirations are a common respiratory manifestation of hypermagnesemia. Hypertension (choice A) is not typically associated with hypermagnesemia. Kussmaul respirations (choice B) are deep, rapid breathing patterns seen in metabolic acidosis, not hypermagnesemia. Increased deep tendon reflexes (DTRs) (choice C) are more indicative of hypomagnesemia, as magnesium deficiency can lead to hyperexcitability of nerves and muscles, resulting in increased DTRs.

Correct Answer: D

Rationale: The correct answer is D: Presence of an ulnar pulse. This is the most important assessment to complete first because the presence of an ulnar pulse indicates adequate circulation in the hand, ensuring that the radial artery catheter is not compromising blood flow. If the ulnar pulse is absent, it may signify impaired circulation and potential complications such as ischemia. Choice A is incorrect because the amount of pressure in the fluid container is not directly related to the assessment of the radial artery catheter. Choice B is incorrect because the date of catheter tubing change is important for infection control but not the immediate priority in this situation. Choice C is incorrect as the percent of heparin in the infusion container is important for anticoagulation therapy but does not take precedence over assessing circulation in the hand.

Correct Answer: D

Rationale: The correct action is to stop the infusion of intravenous fluids. Edema and tenderness above the IV site suggest infiltration, where fluid leaks into surrounding tissues. Stopping the infusion prevents further damage and helps prevent complications. Applying cold compresses (A) may not address the underlying issue. Elevating the extremity (B) is helpful for other conditions like swelling due to dependent edema, not infiltration. Flushing the catheter (C) can exacerbate the issue by pushing more fluid into the tissue.