Priority question; any help appreciated

[TC1087271]

So myself and a couple of my classmates are going over some NCLEX type questions in our book and came across one that a lot of has are half/half on. Here is some background into the case.

Case: A patients' arterial blood gas results include pH: 7.37; PaCO2: 55.4; PaO2:51.2; HCO3: 38; O2 sat:82%. These results are interpreted as compensated respiratory acidosis with hypoxemia.

The question goes as follows:

The nursing assistant took morning vital signs on this patient and immediately reported the following to the nurse. Which takes priorit when notifying the physician?

a. Heart rate 96 per minute

b. Blood pressure 160/90

c. Respiratory rate 34 per minute

d. Temperature 103.5 orally

[jayz1989]

Respiration. Because hr is wnl, bp is high d/t hypoxemia to increase more rbc carrying oxygen. Body is trying to compensate. Hr is high because since patient is in respiratory acidosis the way to compensate is to blow out acid from the respiratory. Ekk! I'm bad in explaining it but, when you apply abc, I would go for respiratory.

[Pandorajinel]

My Kaplan Instructor always broke it down as "Which one is going to make you jump off your chair?". The short cut for that is ABCs. The patient is a respiratory patient and has had a significant change in respiratory status. By ABCs respiratory issues come first.

[oztizz184]

I agree with above. Pt is in respiratory alkalosis. and o2 is low

[Pandorajinel]

I agree with above. Pt is in respiratory alkalosis. and o2 is low

isn't it compensated respiratory acidosis?

[jayz1989]

Yes, it's compensated respiratory acidosis. Increase of respiratory rate is how the patient compensate by blowing out the acid.

[dream2bnurse1234]

Compensated respiratry acidosis

[Double-Helix, BSN, RN]

I disagree with the previous posts. The trick here is to think about what is an expected symptom vs an unexpected symptom.

The patient is in respiratory acidosis- the CO2 is high. The body compensates for the high CO2 by hyperventilating to blos off CO2. The respiratory rate is high, yes, but not unexpected given the ABG.

The heart rate is slightly elevated, but not out of the normal range, and expected given the hypoxemia.

The hypertension is expected, given the ABG as well.

What is NOT expected is the high fever. A fever of 103.5 is not an expected symptom in compensated respiratory acidosis, and indicates a serious infection process in the patient's body. Furthermore, a fever is going to cause an increase in heart rate, blood pressure, and respiratory rate. THIS is the vital sign that needs to be reported so that the cause of the fever can be investigated, cultures can be drawn and antibiotics can be started.

[TC1087271]

Thank you everyone for the reply! Ashley, my friend and I had the same idea as you but a majority of our class thought it was the high RR.

[Double-Helix, BSN, RN]

Does the book have answers to the review questions?