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A nurse is caring for a client who has pneumonia with dyspnea. The client's ABG results are pH 7.30, PaCO2 50 mm Hg, HCO3 26 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

Metabolic acidosis

Respiratory acidosis

Respiratory alkalosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is B

This ABG result indicates that the client has an excess of carbon dioxide (CO2) due to hypoventilation.

A. "Metabolic acidosis" is an incorrect answer because the pH is low and the HCO3 is within normal range.

C. "Respiratory alkalosis" is an incorrect answer because the pH is low and the PaCO2 is elevated.

D. "Metabolic alkalosis" is an incorrect answer because the HCO3 is within normal range, and the pH is low.

Explanation: The ABG result shows a low pH, elevated PaCO2, and normal HCO3, indicating respiratory acidosis. This condition can be caused by conditions that affect breathing, such as pneumonia, asthma, or chronic obstructive pulmonary disease (COPD).

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Correct Answer is B

Explanation

A platelet count of 60,000/mm² is below the expected reference range, and the nurse should report this value to the provider. Ammonia, aspartate aminotransferase, and bilirubin values are within expected reference ranges and do not require further reporting.

Other choices are not correct because:

A. Ammonia 55 mcg/dL: Is within the expected reference range and does not require further reporting.

C. Aspartate aminotransferase 34 units/L: Is within the expected reference range and does not require further reporting.

D. Bilirubin 1.0 mg/dL: Is within the expected reference range and does not require further reporting.

A. Ringing in ears B. Metallic taste C. Rhinitis D. Agitation

Correct Answer is A

Explanation

Ringing in ears. Furosemide is a loop diuretic, which can cause ototoxicity as an adverse effect, resulting in ringing in the ears, hearing loss, or vertigo. The nurse should instruct the client to monitor for these adverse effects and report them immediately if they occur.

An explanation for incorrect choices:

B. Metallic taste is a common adverse effect of metronidazole or clarithromycin, but not furosemide.

C. Rhinitis is associated with intranasal or occasionally oral corticosteroid use.

D. Agitation is a side effect for stimulants, sedatives, or antidepressants.

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A nurse is caring for a client who has pneumonia with dyspnea. The client's ABG results are pH 7.30, PaCO2 50 mm Hg, HCO3 26 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

Nursing Test Bank

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