A client is admited to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?

Metabolic alkalosis

Respiratory acidosis

Metabolic acidosis

Respiratory alkalosis

Answer and Explanation

The Correct Answer is B

Choice A: Metabolic alkalosis is incorrect because it is characterized by a high pH and a high HCO3, not a low pH and a normal HCO3. Metabolic alkalosis occurs when there is a loss of metabolic acids or an excess of bicarbonate in the body, such as from vomiting, gastric suctioning, or diuretic therapy.

Choice B: Respiratory acidosis is correct because it is characterized by a low pH and a high PaCO2. Respiratory acidosis occurs when there is impaired gas exchange or hypoventilation, resulting in accumulation of carbon dioxide in the blood. This can be caused by conditions such as chronic obstructive pulmonary disease (COPD), pneumonia, asthma, or chest trauma.

Choice C: Metabolic acidosis is incorrect because it is characterized by a low pH and a low HCO3, not a low pH and a normal HCO3. Metabolic acidosis occurs when there is an excess of metabolic acids in the body, such as lactic acid, ketoacids, or salicylates.

Choice D: Respiratory alkalosis is incorrect because it is characterized by a high pH and a low PaCO2, not a low pH and a high PaCO2. Respiratory alkalosis occurs when there is excessive loss of carbon dioxide through hyperventilation, such as in anxiety, fever, or aspirin overdose.

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Correct Answer is C

Explanation

Choice A: Sodium 165 mEq/L is incorrect. This value indicates hypernatremia, which is a high level of sodium in the blood. Hypernatremia can be caused by dehydration, but it does not indicate that the client is responding to treatment. A normal sodium level is between 135 and 145 mEq/L.

Choice B: Potassium 5.2 mEq/L is incorrect. This value indicates hyperkalemia, which is a high level of potassium in the blood. Hyperkalemia can be caused by dehydration, but it does not indicate that the client is responding to treatment. A normal potassium level is between 3.5 and 5.0 mEq/L.

Choice C: Urine specific gravity 1.020 is correct. This value indicates that the urine is concentrated, but within the normal range. Urine specific gravity measures the amount of solutes in the urine compared to water. A high urine specific gravity indicates dehydration, while a low urine specific gravity indicates overhydration. A normal urine specific gravity is between 1.005 and 1.030.

Choice D: Hct 62% is incorrect. This value indicates polycythemia, which is a high level of red blood cells in the blood. Polycythemia can be caused by dehydration, but it does not indicate that the client is responding to treatment. A normal hematocrit (Hct) level is between 37% and 52% for men and between 32% and 47% for women.

A. Comfort, Impaired B. Disturbed Sensory Perception C. Deficient Fluid Volume D. Risk for Injury

Correct Answer is B

Explanation

Choice A: Comfort, Impaired is not a priority nursing diagnosis for this patient, because this condition is not directly related to the low sodium level. Comfort, Impaired is a state of physical or psychological discomfort that can aﬀect the patient's well-being and quality of life.

Choice B: Disturbed Sensory Perception is a priority nursing diagnosis for this patient, because this condition is a serious complication of the low sodium level. Disturbed Sensory Perception is a state of altered or impaired perception of reality that can aﬀect the patient's cognitive and neurological functions. Low sodium level can cause cerebral edema, which is a swelling of the brain that can lead to confusion, seizures, coma, and death.

Choice C: Deficient Fluid Volume is not a priority nursing diagnosis for this patient, because this condition is not the cause of the low sodium level. Deficient Fluid Volume is a state of decreased intravascular, interstitial, or intracellular ﬂuid that can aﬀect the patient's ﬂuid and electrolyte balance. Low sodium level can be caused by excess ﬂuid intake, ﬂuid retention, or loss of sodium from the body.

Choice D: Risk for Injury is not a priority nursing diagnosis for this patient, because this condition is not specific to the low sodium level. Risk for Injury is a state of vulnerability to physical or psychological harm that can aﬀect the patient's safety and health. Low sodium level can increase the risk of injury from falls, accidents, or seizures.

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A client is admited to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving IV ﬂuids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is eﬀectively responding to treatment?

Correct Answer is C

Explanation

A nurse is caring for a patient whose sodium level is 118 mEq/L. Which nursing diagnosis is a priority for this patient?

Correct Answer is B

Explanation

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