HELP w/SATA question??

[jojonightengaleGN]

I am confused with this SATA involving ABG's?!? Any help would be much appreciated!!

Q. Client w/ hx of asthma and kidney stones is admitted with a dx of reoccurrence of renal calculi.

Client c/o SOB following a lithotripsy. When the nurse auscultates lungs, noted is decreased air movement but no

wheezing. Client's ABG results are pH 7.31, PaO2 53mm Hg, PaCO2 50mm Hg, and O2 sat @ 82%.

Which of the following actions are appropriate for the nurse to take? ( Select all that apply )

1. Start Oxygen via nasal cannula

2. Contact the Health Care Provider

3. Evaluate the use of intercostal muscles

4. Call respiratory therapy

5. Prepare for possible intubation

6. Increase IV fluids

7. Start High flow oxygen via face mask

( So, when I look at this question scenario... I freak!! - Am I wrong to be directly thinking that this pt. is in resp. distress?)

I don't know if I am "jumping" and assuming??

[WannaBeNrse]

Hmm, I'd say 2,3,4,5,7. He's in resp. acidosis, and yes I also read this as respiratory distress... the PaO2 is really low.

[jojonightengaleGN]

Hmm, I'd say 2,3,4,5,7. He's in resp. acidosis, and yes I also read this as respiratory distress... the PaO2 is really low.

:yeah:

Thank you, just checked and you are correct on your choices!!

[sheila0313]

Yes, I agree with that too. Also when there is no wheezing in asthma patients that's not a good sign, because it could mean no air is moving in the lungs. The airway maybe obstructed with mucus, and that will be your clue also that there's some respiratory distress going on.

[jojonightengaleGN]

:redpinkhe ty

[caliotter3]

These SATA questions sure test one's basic knowledge!

[LoneWolfRN2010]

You aren't "assuming", the information is right there, telling you the patient is in respiratory acidosis.

Remember, with asthma patients, sometimes the cessation of wheezing is BAD, it means airflow is too obstructed and they aren't moving enough air, or have given up trying (been there, done that, and WAS almost intubated myself). This patients O2 if very low.

[jojonightengaleGN]

Thank you all for the help!!

I know that this is a "fundamental question", and I know that it is Resp. Acidosis.

I overthink the questions, I too have asthma.... and after even posting the question, I wanted to remove it because it is OBVIOUS!!

Too many years as a medical assistant, you would think that would help??

Again, I appreciate your responses!!

Go with my GUT!!

[sheila0313]

wheezing can be a bad thing, but in this case or question it's not. because it say's the patient does have a history of asthma, and wheezing would be expected. wheezing would actually let you know that the air is moving. diminished breath sounds may be an indication of severe obstruction and possibly respiratory failure. (reference) : ignatavicius, d., & workman, m. (2002) medical-surgical nursing: critical thinking for collaborative care (4th ed., pp. 532-533). philadelphia: w.b. saunders/size]