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concept of nursing 2
nusrsing diagnosis, Planning, and collaborative interventions related to acid-ba
| Question | Answer |
|---|---|
| A patient is admitted with an acid-base imbalance. The patient’s current assessment data includes hypotension and dysrhythmia. Which is the priority nursing diagnosis that the nurse should include in the plan of care? | Decreased Cardiac Output |
| Which nursing diagnoses should the nurse include in the plan of care for a patient who is experiencing acid-base imbalance, hypoxemia, hypotension, restlessness, anxiety, and decreased oxygen saturation? | -Acute Confusion -Decreased Cardiac Output -Impaired Gas Exchange |
| A patient, who is postoperative for abdominal surgery, presents to the medical-surgical unit from the post-anesthesia care unit (PACU). The nurse’s admission assessment reveals the following: | -- |
| shallow and irregular respirations with a rate of 12 breaths per minute. Lung sounds clear but decreased bilaterally. ABG result post-extubation: pH 7.29, PCO2 46 mm Hg, O2 sat 88%. Which nursing diagnosis is a priority for this patient? | Ineffective Breathing Pattern |
| The nurse is completing a patient’s shift assessment and notes that the patient is lethargic, but restless and agitated. Which nursing diagnosis should the nurse include to the plan of care based on this data? | Acute Confusion |
| The nurse formulates a nursing diagnosis of Decreased Cardiac Output for a patient admitted with metabolic acidosis. The goal statement is: the patient’s blood pressure will return to baseline or WNL within 24 hours of admission. | -- |
| Which NOC outcome should the nurse include in the plan of care? | Tissue Perfusion: Vital Signs |
| The nurse is planning care for a patient who is experiencing metabolic alkalosis and formulates the nursing diagnosis Acute Confusion. Which NOC outcomes are appropriate for the nurse to include in the plan of care? | -Cognition -Information Processing -Memory |
| An older adult patient reports fatigue, decreased energy, and difficulty breathing. The medical diagnosis is respiratory acidosis with metabolic compensation. The nurse formulates a nursing diagnosis of Fatigue. | -- |
| Which goal statement should the nurse include in the plan of care? | Patient will verbalize feelings of increased energy within 24 hours of admission. |
| The patient’s ABG analysis is as follows: pH – 7.2; PaCO2 – 60 mm Hg; PaO2 – 73 mm Hg; HCO3− – 25 mEq/L. The nurse identifies the nursing diagnostic statement of Impaired Gas Exchange r/t COPD AEB ABG results. | -- |
| Which goal statement should the nurse include in the plan of care? | Patient’s pH value will return to a level between 7.35 and 7.45 within 12 hours. |
| Which intervention should the nurse include in the plan of care for a patient who is experiencing respiratory alkalosis? | Breathing into a paper bag |
| Which nursing action is appropriate when providing care to a patient who is experiencing metabolic alkalosis? | Initiating seizure precautions |
| The nurse is planning a collaborative care conference for a patient diagnosed with an acid-base imbalance. Which members of the healthcare team should the nurse include during the acute phase of any acid-base imbalance? | -Primary care provider (PCP) -Respiratory therapist (RT) |
| Which interventions should the nurse implement for a patient who is experiencing respiratory acidosis? | -Encourage deep breathing exercises -Monitor breath sounds -Provide emotional support |
Created by:
Lightnning54
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