A client with a bowel obstruction is experiencing intractable vomiting for the last several hours despite the administration of prescribed antiemetics. The nurse obtains the client's arterial blood gas (ABG) results which identify a pH of 7.50, a PaCO2 of 42 mm Hg, and an HCO3 of 33 me/L (33 mmol/L). The nurse should interpret these results as confirming which acid-base imbalance?

Respiratory acidosis.

Metabolic acidosis.

Metabolic alkalosis.

Respiratory alkalosis.

Answer and Explanation

The Correct Answer is C

Choice A reason: Respiratory acidosis is characterized by a low pH and an elevated PaCO2 due to hypoventilation, which results in CO2 retention. The ABG results in this case show a normal PaCO2, making this option incorrect.

Choice B reason: Metabolic acidosis is characterized by a low pH and a low HCO3 due to an accumulation of acids or loss of bicarbonate. The ABG results show a high pH and a high HCO3, which are opposite to the findings of metabolic acidosis.

Choice C reason: Metabolic alkalosis is characterized by a high pH and an elevated HCO3. This condition can result from excessive loss of stomach acid due to vomiting or the use of diuretics. The ABG results show a pH of 7.50 and HCO3 of 33 me/L, both indicative of metabolic alkalosis.

Choice D reason: Respiratory alkalosis is characterized by a high pH and a low PaCO2 due to hyperventilation, which leads to CO2 loss. The ABG results show a normal PaCO2, ruling out respiratory alkalosis as the correct diagnosis.

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Correct Answer is B

Explanation

Choice A reason: Testing the urine for the presence of haematuria is important for diagnosing a urinary tract infection (UTI) or kidney stones, but it is not the most immediate intervention. Haematuria indicates blood in the urine, but assessing the client's vital signs is more urgent to determine if there is an acute issue that requires immediate attention.

Choice B reason: Measuring her temperature and heart rate is the most critical first step. These vital signs can provide immediate information about the client's overall condition and help identify potential systemic infection (fever) or hemodynamic instability (tachycardia). This information is essential for prioritizing further interventions and determining the urgency of the situation.

Choice C reason: Evaluating the urine for a strong Odor can help identify the presence of a UTI, but it is not as immediately critical as assessing the client's vital signs. Changes in urine Odor can support a diagnosis, but they do not provide the urgent information needed to assess the client's immediate health status.

Choice D reason: Palpating the right flank for tenderness is important for assessing kidney involvement, such as in cases of pyelonephritis (kidney infection). However, this physical examination should follow the assessment of vital signs to ensure the client is stable and not in immediate danger.

A. Start pelvic floor exercises. B. Report fever or chills. C. Increase fluid intake to help with hydration. D. Tape urinary catheter securely to the thigh.

Correct Answer is A

Explanation

Choice A reason: Starting pelvic floor exercises might be beneficial in the long term for improving urinary control after TURP. However, immediately following the surgery and while the indwelling catheter is in place, it may not be the appropriate time to begin these exercises. The nurse should clarify when and how to start pelvic floor exercises.

Choice B reason: Reporting fever or chills is crucial because these symptoms could indicate an infection, which requires prompt medical attention. This statement reflects an understanding of important post-operative care instructions and does not need clarification.

Choice C reason: Increasing fluid intake to help with hydration is important for clients with a urinary catheter. Adequate hydration helps flush the urinary system and prevent complications such as urinary tract infections. This statement does not need clarification.

Choice D reason: Taping the urinary catheter securely to the thigh helps prevent tension on the catheter and reduces the risk of accidental dislodgement or trauma. This instruction is correct and does not need clarification.

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Naxlex Comprehensive Predictor Exams

A female college student comes to the school's health clinic reporting urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

The nurse is providing education to a client who is returning home with an indwelling urinary catheter after having a transurethral resection of the prostate (TURP). Which statement made by the client demonstrates a need for the nurse to clarify the instructions?

Correct Answer is A

Explanation

After initializing a steroid nebulizer treatment for an asthmatic client in respiratory distress, which intervention is most important for the nurse to implement?

A client with Crohn's disease is admitted to the medical unit with a three-day history of abdominal cramping, nausea, and vomiting. Which prescription should the nurse implement first?

The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behaviour indicates that the client is adhering to the eating plan?

The home health nurse visits a client who has a serum sodium level of 123 me/L (123 mmol/L). To explore possible etiologist for this value, what question should the nurse ask the client?

A client with type 1 diabetes mellitus calls the home care nurse and reports taking a morning dose of 70/30 insulin before realizing they have a stomach virus and are now unable to eat breakfast due to nausea. Which initial instruction should the nurse provide the client?

An older female resident of a long-term care facility with early-stage Alzheimer's disease frequently wanders into the wrong room. To help this client recognize her room, which intervention should the nurse implement?

In planning care for a client with chronic ulcerative colitis, which long-term goal is most important for the nurse to include?

A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?