A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following:

- pH is 7.12 (normal range: 7.35-7.45)

- PaCO2 is 90 mm Hg (normal range: 35-45)

- HCO3- is 22 mEq/L (normal range: 22-26)

The nurse interprets the results as indicating which condition?

Metabolic alkalosis

Respiratory alkalosis

Respiratory acidosis

Metabolic acidosis

Answer and Explanation

The Correct Answer is C

A. Metabolic alkalosis is characterized by a high pH and elevated bicarbonate levels, which is not present in these results.

B. Respiratory alkalosis would present with an increased pH and decreased PaCO2, which does not apply here.

C. The low pH (7.12) indicates acidemia, and the elevated PaCO2 (90 mm Hg) suggests hypoventilation and respiratory acidosis due to CO2 retention. The bicarbonate level is within normal limits, further supporting respiratory acidosis.

D. Metabolic acidosis would be indicated by a low pH and low bicarbonate levels; however, the bicarbonate is normal in this case, ruling out metabolic acidosis.

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Correct Answer is C

Explanation

A. The patient's chart may provide historical information but does not reflect the current pain intensity the client is experiencing.

B. Visual observation for nonverbal signs of pain can be useful, especially for nonverbal patients, but self-reporting is the most accurate measure of pain intensity.

C. The client's self-report of pain severity is the gold standard for assessing pain intensity, as it reflects the individual’s personal experience of pain.

D. While the nature and invasiveness of the surgical procedure can provide context for expected pain levels, they do not replace the importance of the client's self-report in managing pain effectively.

A. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. B. The nurse will briefly touch the client, and the client will need to identify where the touch occurred. C. Client will close their eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. D. The client is to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time.

Correct Answer is C

Explanation

A. This description relates more to a sensory discrimination test, not graphesthesia.

B. This option does not accurately describe the graphesthesia test, which involves identifying shapes or numbers rather than just touch location.

C. In the graphesthesia test, the client closes their eyes while the nurse uses a blunt object to write a number or shape in the client's palm, and the client must identify what was written. This assesses the ability to recognize letters or numbers drawn on the skin.

D. This option describes a two-point discrimination test rather than graphesthesia, which focuses on identifying drawn shapes or numbers.

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A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following: - pH is 7.12 (normal range: 7.35-7.45) - PaCO2 is 90 mm Hg (normal range: 35-45) - HCO3- is 22 mEq/L (normal range: 22-26) The nurse interprets the results as indicating which condition?

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Naxlex Comprehensive Predictor Exams

. A nurse is caring for a postoperative client. The nurse should base the client's pain management interventions primarily on which methods of determining the intensity of the client's pain?

Correct Answer is C

Explanation

A nurse is precepting a nursing student. The nurse explains to the nursing student how you would perform the graphesthesia test on a client. What is the correct way to perform this test?

Correct Answer is C

Explanation

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The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, [normal range: 7.35-7.45] Paco2 of 30 mm Hg (30 mmol/L), [normal range: 35-45] HCO3- of 20 mEq/L (20 mmol/L), [normal range: 22-26] Which condition would the nurse analyze these results to indicate?

A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following:

- pH is 7.12 (normal range: 7.35-7.45)

- PaCO2 is 90 mm Hg (normal range: 35-45)

- HCO3- is 22 mEq/L (normal range: 22-26)

The nurse interprets the results as indicating which condition?