A client is brought into the emergency department for an overdose of morphine. The client has a respiratory rate of 5 to 8 breaths per minute. Which of the following ABG results would the nurse expect to see?
pH 7.45, PaCO2 35, HCO3 22
pH 7.25. PaCO2 61, HCO3 26
pH 7.23. PaCO2 27, HCO3 25
pH 7.54, PaCO2 59. HCO3 26
The Correct Answer is B
B. pH 7.25, PaCO2 61, HCO3 26
pH is decreased (acidosis).
PaCO2 is elevated (61 mmHg), indicating respiratory acidosis (increased CO2 retention). HCO3 is slightly elevated (26 mEq/L), compensating for the respiratory acidosis.
A. pH 7.45, PaCO2 35, HCO3 22
pH is within normal range (7.35-7.45).
PaCO2 is slightly lower than normal (35 mmHg), indicating mild respiratory alkalosis. HCO3 (bicarbonate) is within normal range (22 mEq/L).
C. pH 7.23, PaCO2 27, HCO3 25
pH is decreased (acidosis).
PaCO2 is lower than normal (27 mmHg), indicating respiratory alkalosis (which is unlikely in the context of morphine overdose with hypoventilation).
HCO3 is within normal range (25 mEq/L).
D. pH 7.54, PaCO2 59, HCO3 26
pH is increased (alkalosis).
PaCO2 is elevated (59 mmHg), indicating respiratory acidosis (consistent with hypoventilation). HCO3 is slightly elevated (26 mEq/L), compensating for the respiratory acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Expected outcomes are specific, measurable criteria used to determine goal achievement. These outcomes are set during the planning phase of the nursing process in collaboration with the client. During evaluation, the nurse compares the client's actual progress with these expected outcomes. This assessment helps determine whether the goals were met, partially met, or not met, which guides further nursing actions.
A. During the evaluation phase, the nurse assesses the effectiveness of these interventions in achieving the desired outcomes rather than the interventions themselves. The focus is on determining whether the interventions were appropriate, timely, and effective in meeting the client's goals.
C Definitions typically refer to the meaning or understanding of terms used in the nursing process, such as nursing diagnoses or medical conditions. They provide clarity and context to ensure accurate assessment, planning, and intervention. However, definitions themselves are not directly evaluated in the evaluation phase of the nursing process.
D. In the evaluation phase, the nurse assesses the client's response to interventions aimed at addressing these diagnoses. The focus is on determining the effectiveness of the care provided rather than evaluating the diagnoses themselves.
Correct Answer is B
Explanation
B. Teaching preschoolers how to wash their hands correctly is an example of primary prevention. By educating children on proper hand hygiene practices, nurses aim to reduce the spread of infections and promote good health habits. This activity focuses on preventing the transmission of infectious diseases and promoting overall wellness among children
A. Screening for high blood pressure is an example of secondary prevention rather than primary prevention. Secondary prevention involves early detection and treatment to halt or slow down the progress of a disease.
C. Providing hospice care is a form of palliative care that focuses on improving the quality of life for terminally ill clients and their families. It aims to provide comfort and support rather than preventing disease onset. Therefore, it does not fall under primary prevention but rather under supportive care for those with advanced illness.
D. Teaching a client how to self-administer insulin is an example of tertiary prevention. Tertiary prevention involves managing and reducing the impact of a disease that has already occurred. In this case, teaching self-administration of insulin helps manage diabetes, prevent complications, and promote optimal health outcomes for the client.
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