High = obstruction · Low = disconnection
Before you read
Test yourself first: 2 questions
Question 1 of 2
A client with a cervical spinal cord injury at C4 is admitted. Which is the nurse's HIGHEST priority assessment?
Answer: A. Injury at or above C4 can paralyze the diaphragm (innervated by C3 to C5), so respiratory status and airway are the highest priority. Loss of ventilatory drive is immediately life-threatening. Bladder distention, skin breakdown, and bowel sounds are important but secondary to airway and breathing.
Question 2 of 2
A client receiving mechanical ventilation has the rate set too high and develops pH 7.50, PaCO2 28 mmHg, HCO3 24 mEq/L. Which action should the nurse anticipate?
Answer: A. These values show respiratory alkalosis from iatrogenic overventilation. Lowering the ventilator respiratory rate (or tidal volume) allows CO2 to rise back toward normal and corrects the alkalosis. Adding bicarbonate or increasing the rate would worsen the alkalosis.
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References
Clinical references for this topic
