CRNE Exam Prep

Category - Changes in Health

The nurse assessing Fran, a 39-year-old female with a history of asthma, notes increase in respiratory rate, rapid and irregular pulse, and mental status changes. Laboratory results reveal that the client has respiratory acidosis. Which of the following nursing interventions is the most appropriate for the client?
  1. Assist the client in voluntary holding of breath.
  2. Administer oxygen.
  3. Administer tranquilizers, as prescribed.
  4. Encourage use of rebreathing mask.
Explanation
Answer: B - The most appropriate intervention for a client with respiratory acidosis is to administer oxygen. The client must be placed in semi-Fowler’s position and encouraged to perform coughing exercises. Voluntary holding of breath and use of a rebreathing mask are more appropriate for a client with respiratory alkalosis. Tranquilizers should not be administered to reduce restlessness because they can further depress the client’s respirations.
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