A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are pH 7.48, PCO2 30 mm Hg, HCO3 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing?
Respiratory alkalosis.
Respiratory acidosis.
Metabolic alkalosis.
Metabolic acidosis.
The Correct Answer is A
Choice A rationale:
The client's ABG values show a pH of 7.48, PCO2 of 30 mm Hg, HCO3 of 24 mEq/L, and PaO2 of 85 mm Hg. The elevated pH and decreased PCO2 (respiratory component) suggest respiratory alkalosis. Respiratory alkalosis occurs when there is excessive ventilation, leading to a decrease in carbon dioxide levels (hypocapnia) and subsequent alkalosis.
Choice B rationale:
Respiratory acidosis is characterized by an elevated PCO2 and decreased pH. In this case, the client's PCO2 is decreased, indicating respiratory alkalosis rather than respiratory acidosis.
Choice C rationale:
Metabolic alkalosis is characterized by an elevated HCO3 (bicarbonate) level and an increased pH. The client's HCO3 level is within the normal range, making metabolic alkalosis an incorrect identification.
Choice D rationale:
Metabolic acidosis is characterized by a decreased HCO3 level and a decreased pH. The client's HCO3 level is within the normal range, ruling out metabolic acidosis as the acid-base imbalance in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Expiratory rhonchi are typically associated with conditions such as chronic bronchitis or asthma but are not specific to pulmonary embolism.
Choice B rationale:
Petechiae over the lower extremities is not a characteristic finding in pulmonary embolism. Petechiae are tiny red or purple spots that appear due to bleeding under the skin and may be associated with other conditions like thrombocytopenia.
Choice C rationale:
The correct choice. Hemoptysis, which refers to coughing up blood, is a concerning finding in pulmonary embolism. It occurs due to the obstruction of blood flow in the pulmonary vasculature, leading to blood leaking into the lungs.
Choice D rationale:
Flattened neck veins are more likely to be observed in conditions associated with decreased venous return to the heart, such as hypovolemia or cardiac tamponade, and are not directly related to pulmonary embolism.
Correct Answer is C
Explanation
Choice A rationale:
A 23-year-old client in skeletal traction may be at risk of pressure injuries, but being young and presumably healthier than the other options, this client may have a lower risk compared to the other choices.
Choice B rationale:
A 67-year-old client with coronary artery disease may be at risk of pressure injuries, especially if the client has limited mobility or is bedridden. However, coronary artery disease alone does not significantly increase the risk of pressure injuries.
Choice C rationale:
A 32-year-old client with a spinal cord injury is most at risk of developing a pressure injury. Spinal cord injuries often result in paralysis or limited mobility, leading to prolonged pressure on specific areas of the body, which can cause pressure ulcers.
Choice D rationale:
A 55-year-old client with emphysema may have compromised lung function, but this alone does not significantly increase the risk of pressure injuries. Pressure injuries are primarily related to immobility and pressure on specific body areas.
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