A nurse is caring for a patient who has the following arterial blood values: pH 7.12, PaO 56 mm Hg, PaCO 65 mm Hg, and HCO - 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values?

Diabetic ketoacidosis in a person with emphysema

Diarrhea for 36 hours in an older, frail woman

Anxiety-induced hyperventiIation in an adolescent

Bronchial obstruction related to aspiration of a hot dog

Answer and Explanation

The Correct Answer is D

A. Diabetic ketoacidosis (DKA) in a person with emphysema:

In DKA, there is typically metabolic acidosis due to the accumulation of ketones in the blood, leading to a decrease in pH. However, the respiratory compensation mechanism in DKA usually results in a decreased PaCO2 (respiratory alkalosis) rather than an elevated PaCO2 as seen in the blood gas values provided. Additionally, emphysema is associated with chronic respiratory acidosis, not respiratory alkalosis as indicated by the elevated PaCO2.

B. Diarrhea for 36 hours in an older, frail woman:

Prolonged diarrhea can lead to metabolic acidosis due to the loss of bicarbonate through the gastrointestinal tract. The pH of 7.12 and the decreased HCO3- (22 mEq/L) suggest metabolic acidosis. However, the elevated PaCO2 (respiratory acidosis) is not consistent with pure metabolic acidosis caused by diarrhea. Respiratory acidosis typically occurs due to hypoventilation or respiratory dysfunction.

C. Anxiety-induced hyperventilation in an adolescent:

Anxiety-induced hyperventilation can lead to respiratory alkalosis due to excessive blowing off of CO2, resulting in a decrease in PaCO2. The pH of 7.12 is consistent with acidosis, but the elevated PaCO2 contradicts respiratory alkalosis. Anxiety-induced hyperventilation would typically result in a higher pH and lower PaCO2.

D. Bronchial obstruction related to aspiration of a hot dog:

A bronchial obstruction causing inadequate ventilation can lead to respiratory acidosis due to CO2 retention. The pH of 7.12 and the elevated PaCO2 (65 mm Hg) indicate respiratory acidosis. This situation is consistent with the blood gas values provided.

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Correct Answer is A

Explanation

A. Colonization - replicating microorganisms: not yet Infected

This pairing is correct. Colonization refers to the presence and replication of microorganisms on the wound surface. At this stage, the wound is not yet infected, as there may be microorganisms present, but they have not caused an inflammatory response or tissue damage.

B. Systemic infection - Wound is darker than the surrounding skin with noted drainage present

This description does not match the stage of systemic infection. Systemic infection refers to an infection that has spread beyond the initial wound site, affecting the entire body systemically. The symptoms of systemic infection may include fever, increased heart rate, malaise, and altered mental status. The description provided seems more indicative of a local infection with drainage.

C. Contaminated - infection beyond the wound

This pairing is incorrect. Contaminated wounds refer to wounds with a high risk of infection due to the presence of foreign material or significant contamination. However, contamination does not necessarily mean that an infection has already developed beyond the wound. It signifies a risk of infection but does not define the infection stage itself.

D. Local infection - sepsis

This pairing is incorrect. A local infection is confined to the wound site and may present with symptoms such as erythema, warmth, swelling, pain, and purulent drainage. Sepsis, on the other hand, is a severe systemic response to infection, characterized by widespread inflammation and organ dysfunction. Sepsis is not synonymous with a local infection; it represents a more advanced and life-threatening stage of infection.

A. “Call your surgeon if you have any questions at home.” B. ”Eat a diet high in protein, iron, zinc, and vitamin C.” C. “Wash your hands before touching the drain or dressing." D. “Be sure you keep all your postoperative appointments.”

Correct Answer is C

Explanation

A. “Call your surgeon if you have any questions at home.”

This instruction is important as it encourages the patient to seek help and clarification if they have any concerns or questions about their postoperative care at home. However, while communication with the surgeon is essential, it is not as immediately critical as ensuring proper hand hygiene when dealing with wound care and drain management.

B. ”Eat a diet high in protein, iron, zinc, and vitamin C.”

Nutritional advice is crucial for postoperative recovery, as a balanced diet high in protein, iron, zinc, and vitamin C can promote wound healing and overall recovery. However, while important for long-term recovery and healing, dietary recommendations do not directly address the immediate risk of infection or complications associated with wound care and drain management.

C. “Wash your hands before touching the drain or dressing."

This instruction is the most important in this context because proper hand hygiene is crucial for preventing infections during wound care and drain management. Clean hands significantly reduce the risk of introducing harmful bacteria or contaminants to the surgical site, which can lead to infections and other complications. Ensuring that the patient washes their hands before touching the drain or dressing is a fundamental measure for promoting wound healing and preventing postoperative complications.

D. “Be sure you keep all your postoperative appointments.”

Keeping postoperative appointments is important for ongoing assessment, monitoring, and follow-up care. However, while essential for overall recovery and management of postoperative issues, it is not as immediate or directly related to the patient's ability to manage their dressing and drain at home.

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A nurse is caring for a patient who has the following arterial blood values: pH 7.12, PaO 56 mm Hg, PaCO 65 mm Hg, and HCO - 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a wound. Which of the following pairings reflect the correct wound infection stage with description?

Correct Answer is A

Explanation

A nurse is preparing a patient for discharge after surgery. The patient needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

Correct Answer is C

Explanation

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