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 respiratory alkalosis is a condition where the blood pH is higher than the normal range of 7.35 to 7.45, due to hyperventilation, which lowers the carbon dioxide in the blood. Severe diarrhea does not cause hyperventilation, but rather dehydration and electrolyte imbalance.
Choice B reason: This is incorrect because metabolic 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. Severe diarrhea does not cause a loss of acids or an excess of bases, but rather a loss of fluids and bicarbonate, which is a base that buffers the acids in the blood.
Choice C reason: This is correct because 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. Severe diarrhea causes a loss of fluids and bicarbonate, which is a base that buffers the acids in the blood. This leads to an accumulation of acids and a decrease in pH.
Choice D reason: This is incorrect because 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. Severe diarrhea does not affect the respiratory system directly, but rather the metabolic system.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because intracellular fluid is greater than extracellular fluid in a hypertonic state, not an isotonic state. A hypertonic state is when the solute concentration of the extracellular fluid is higher than the intracellular fluid, which causes water to move out of the cells and shrink them.
Choice B reason: This is incorrect because extracellular fluid is less than intracellular fluid in a hypotonic state, not an isotonic state. A hypotonic state is when the solute concentration of the extracellular fluid is lower than the intracellular fluid, which causes water to move into the cells and swell them.
Choice C reason: This is correct because intracellular and extracellular fluid is equal in an isotonic state. An isotonic state is when the solute concentration of the extracellular fluid is the same as the intracellular fluid, which causes no net movement of water across the cell membrane.
Choice D reason: This is incorrect because interstitial fluid is less than the transcellular fluid in a situation of fluid imbalance, not an isotonic state. Interstitial fluid is the fluid that surrounds the cells, while transcellular fluid is the fluid that is contained in specialized cavities, such as cerebrospinal fluid, synovial fluid, or pleural fluid. The amount of transcellular fluid is normally very small compared to the interstitial fluid, but it can increase in certain conditions, such as edema, ascites, or hydrocephalus.
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