A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The arterial blood gas values are pH 6.88, PaO2 50 mmHg PaCO2 60 mmHg, and HCO3 22mEq/L. Which action should the nurse take first?

Administer 50mL of sodium bicarbonate IV

Apply oxygen by mask or nasal cannula

Apply a paper bag over the client's nose and mouth

Administer 50mL of 20% glucose and 20 units of regular insulin IV

Answer and Explanation

The Correct Answer is B

Rationale:
A. Sodium bicarbonate may be used to correct acidosis, but oxygenation must be addressed first to prevent further deterioration.
B. The first priority is to improve oxygenation. Administering oxygen by mask or nasal cannula is the most immediate and effective way to increase PaO₂ and support respiratory function.
C. A paper bag is used for respiratory alkalosis, not acidosis—it would worsen hypoxemia.
D. Glucose and insulin are used for hyperkalemia, which is not the current priority.

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Correct Answer is D

Explanation

Rationale:
A. An erythrocyte sedimentation rate (ESR) is used to detect inflammation but is not relevant in the immediate management of hyperkalemia.
B. Administering potassium would worsen the client's already elevated potassium level.
C. Restricting fluids is not an appropriate initial response for hyperkalemia and can increase the risk of complications.
D. A potassium level of 6.8 mEq/L is critically high and can cause life-threatening cardiac dysrhythmias. A 12-lead ECG is essential to assess for cardiac effects of hyperkalemia, such as peaked T waves or widened QRS complexes.

A. Elevate the head of the bed to high Fowler's. B. Check the client's respiratory rate and lung sounds C. Measure the client's temperature. D. Request NPO status for the client.

Correct Answer is B

Explanation

Rationale:
A. Elevating the head of the bed is appropriate for respiratory distress, but the priority is to assess for signs of fluid overload.
B. The IV infused 900 mL in just 30 minutes, which is a dangerously rapid rate and can lead to fluid volume overload, especially in vulnerable clients. The nurse should assess for signs such as increased respiratory rate and crackles in the lungs, indicating pulmonary edema.
C. Measuring temperature is not the priority in this situation and does not relate directly to fluid overload.
D. NPO status does not address the immediate concern of a rapid IV infusion and its potential consequences.

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A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The arterial blood gas values are pH 6.88, PaO2 50 mmHg PaCO2 60 mmHg, and HCO3 22mEq/L. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L. The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?

Correct Answer is D

Explanation

During a change-of-shift report, a nurse sees that a client's IV bag of 0.9% sodium chloride has 900 mL of fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who is at risk for metabolic acidosis. Which mechanism should the nurse identify as the first line of defense against changes in the pH of the blood?

A nurse is caring for an older adult client who has a new prescription for spironolactone. Which of the following laboratory values should the nurse monitor for this client?

Interpret the ABG: pH 7.41, PaCO2 45mmHg. HCO3 26, PaO2 84 mmHg. SaO2 97%

Interpret the following ABG: pH 7.49, pCo2 30 mmHg, HCO3 23 Meq/L. PaO2 96 mmHg. SaO2 98%

The nurse is caring for a client experiencing respiratory alkalosis. Which of these conditions is a causative agent?

A nurse is reviewing the laboratory values of a client who is receiving total parenteral nutrition (TPN): glucose 72 mg/dL, chloride 100 mEq/L. sodium 138 mEq/L. and potassium 3.0 mEq/L. Which of the following actions should the nurse plan to take?

An emergency department nurse admits a client who has tried to commit suicide by taking an overdose of hydromorphone (Dilaudid), a narcotic. For which acid-base imbalance should the nurse assess this client for?

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