The nurse is caring for an older adult client with heart failure (HF) whose arterial blood gas (ABG) results include a pH 7.38, PaCO2 40 mm Hg, HCO3- 24 mEq/L (24 mmol/L), and a PaO2 90 mm Hg. Which action should the nurse implement? Reference Range: Arterial Blood Gas (ABG) pH [7.35 to 7.45] PaCO2 [35 to 45 mm Hg] HCO3- [21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg]

A. Continue to monitor the client's condition: The ABG values are all within normal limits: pH 7.38, PaCO₂ 40 mm Hg, HCO₃⁻ 24 mEq/L, and PaO₂ 90 mm Hg. This indicates adequate acid-base balance and oxygenation. No immediate intervention is needed, so continued monitoring is the most appropriate nursing action. B. Encourage the client to cough and deep breathe: Coughing and deep breathing are useful for clearing secretions or improving oxygenation in clients with hypoxia or atelectasis. However, the client’s PaO₂ is within the normal range, so this intervention is unnecessary. C. Administer oxygen per face mask per PRN protocol: Supplemental oxygen is used when PaO₂ levels are below normal or when signs of respiratory distress are present. Since the client’s PaO₂ is 90 mm Hg, which is normal, there is no need to initiate oxygen therapy. D. Instruct the client to breathe into a paper bag: Breathing into a paper bag is used to treat hyperventilation leading to respiratory alkalosis. The client’s ABG results do not show alkalosis; therefore, this intervention would be inappropriate and potentially harmful.