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sherpath week 14

Nursing Diagnosis, Planning, and Collaborative Interventions Related to Acid-Bas

QuestionAnswer
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
Mr. Abdul states, “I can’t catch my breath.” The nurse observes that his breathing is labored, his respirations are slow and deep, and his oxygen saturation level is 90%. Based on these assessment findings, which nursing diagnosis does the nurse include i Impaired Gas Exchange
Match each nursing diagnosis with the appropriate cluster of assessment data about Mr. Abdul. Dyspnea, labored breathing, PaCO2 = 60 Restless, anxiety, unsure about current events Unable to fix meals and take medication - Impaired Gas Exchange - Acute Confusion - Self- Care Dificit
Order the nursing diagnoses for Mr. Abdul’s plan of care from highest priority to lowest priority. - Impaired Gas Exchange - Risk for Injury - Acute Confusion - Self-Care Deficit
Which NOC outcome is appropriate for Mr. Abdul’s nursing diagnosis of Acute Confusion? - Cognition - Distorted Thought Self-Control - Information Processing - Memory
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 includ Patient’s pH value will return to a level between 7.35 and 7.45 within 12 hours.
Match each nursing diagnosis with its corresponding goal statement for Mr. Abdul. Patient’s blood pressure will return to baseline within 24 hours.Patient is able to perform usual ADLs during hospitalization.Patient’s ABG results will return to baseline/ - Decreased Cardiac Output - Self-Care Deficit - Impaired Gas Exchange - Acute Confusion
Which NOC outcome is appropriate when planning care based on Mr. Abdul’s nursing diagnosis of Decreased Cardiac Output? Tissue Perfusion: Vital Signs
Which interventions should the nurse implement for a patient who is experiencing respiratory acidosis? - Encourage deep breathing exercises - Monitor breath sounds - Provide emotional support
Which nursing intervention is appropriate for all patients who are experiencing an acid-base imbalance? Monitoring the ABG analysis
Which collaborative nursing intervention is appropriate for a patient who is experiencing respiratory alkalosis? Asking the patient to breathe slowly into a paper bag
Which intervention is appropriate for a patient who is experiencing metabolic acidosis? Sodium bicarbonate
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 pe 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 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 inclu Patient will verbalize feelings of increased energy within 24 hours of admission.
Which intervention should the nurse include in the plan of care for a patient who is experiencing respiratory alkalosis? Breathing into a paper bag
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 includ Patient’s pH value will return to a level between 7.35 and 7.45 within 12 hours.
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: Brandi Sizemore
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