A client has the following laboratory values: a pH of 7.55, an HCO3 level of 22 mEq/L, and a PaCO2 of 30 mmHg. Which action would the nurse plan to take?
Prepare the client for IV infusion of normal saline
Perform Allen's test
Encourage the client to increase breathing
Encourage the client to slow down breathing
The Correct Answer is D
Choice A reason: This is incorrect because normal saline is not indicated for this client. Normal saline is a isotonic solution that does not alter the acid-base balance. The client has respiratory alkalosis, which is caused by hyperventilation and results in a high pH and a low PaCO2.
Choice B reason: This is incorrect because Allen's test is not relevant for this client. Allen's test is a test to assess the patency of the radial and ulnar arteries before performing an arterial blood gas (ABG) sampling or cannulation. The client already has ABG results, so there is no need to perform Allen's test.
Choice C reason: This is incorrect because increasing breathing would worsen the client's condition. Increasing breathing would cause the client to exhale more carbon dioxide, which would lower the PaCO2 and raise the pH even more. This would increase the severity of respiratory alkalosis.
Choice D reason: This is correct because slowing down breathing would help the client to correct the respiratory alkalosis. Slowing down breathing would allow the client to retain more carbon dioxide, which would increase the PaCO2 and lower the pH. This would bring the acid-base balance closer to normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because low HCO3- and high PaCO2 are signs of metabolic acidosis, not alkalosis. Metabolic acidosis is a condition where the blood pH is lower than the normal range of 7.35 to 7.45, due to an excess of acids or a loss of bases in the body.
Choice B reason: This is incorrect because low PaCO2 and low HCO3- are signs of respiratory acidosis, not alkalosis. Respiratory acidosis is a condition where the blood pH is lower than the normal range of 7.35 to 7.45, due to impaired gas exchange or hypoventilation, which causes carbon dioxide to accumulate in the blood.
Choice C reason: This is correct because low PaCO2 and high HCO3- are signs of alkalosis. Alkalosis is a condition where the blood pH is higher than the normal range of 7.35 to 7.45, due to a loss of acids or an excess of bases in the body. There are two types of alkalosis: respiratory and metabolic. Respiratory alkalosis is caused by hyperventilation, which lowers the PaCO2 in the blood. Metabolic alkalosis is caused by vomiting, diuretics, or excessive intake of antacids, which raises the HCO3- in the blood.
Choice D reason: This is incorrect because high PaCO2 and high HCO3- are signs of compensation, not alkalosis. Compensation is a process where the body tries to restore the normal pH by adjusting the levels of PaCO2 and HCO3- in the opposite direction of the primary disorder. For example, if the patient has metabolic alkalosis, the respiratory system will try to compensate by retaining carbon dioxide and lowering the PaCO2. If the patient has respiratory alkalosis, the renal system will try to compensate by excreting bicarbonate and lowering the HCO3-.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because bradypnea is a term for slow breathing, usually less than 12 breaths per minute. The client is breathing rapidly, not slowly.
Choice B reason: This is correct because Kussmaul's respirations are a type of breathing pattern that is deep, regular, and rapid, usually more than 20 breaths per minute. Kussmaul's respirations are a sign of metabolic acidosis, which occurs in diabetic ketoacidosis due to the accumulation of ketones in the blood. The client is trying to exhale the excess carbon dioxide and lower the acidity of the blood.
Choice C reason: This is incorrect because Cheyne-Stokes respirations are a type of breathing pattern that is irregular, with periods of apnea (no breathing) alternating with periods of rapid breathing. Cheyne-Stokes respirations are a sign of cerebral dysfunction, such as stroke, brain injury, or coma.
Choice D reason: This is incorrect because Biot's respirations are a type of breathing pattern that is irregular, with periods of apnea (no breathing) interspersed with periods of normal breathing. Biot's respirations are a sign of brainstem damage, such as meningitis, encephalitis, or head trauma.
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