A nurse is reviewing a client's laboratory report of arterial blood gas (ABG) findings: pH 7.28, HCO3 18, and PaCO2 36. Which of the following conditions should the nurse anticipate when interpreting these findings?

Metabolic alkalosis

Respiratory alkalosis

Metabolic acidosis

Respiratory acidosis

Answer and Explanation

The Correct Answer is C

Choice A reason: Metabolic alkalosis would present with an elevated pH and HCO3, which is not the case here.

Choice B reason: Respiratory alkalosis would present with an elevated pH and a decreased PaCO2, which is not the case here.

Choice C reason: Metabolic acidosis is indicated by a decreased pH and HCO3, which aligns with the ABG findings provided.

Choice D reason: Respiratory acidosis would present with a decreased pH and an elevated PaCO2, which is not the case here.

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Correct Answer is D

Explanation

Choice A reason: Anorexia, or loss of appetite, is not typically a direct manifestation of left-sided heart failure. While it can be associated with many medical conditions and may occur in the context of heart failure due to overall decreased well-being, it is not a specific indicator of left-sided heart failure.

Choice B reason: Weight gain can be associated with heart failure, but it is more commonly a sign of right-sided heart failure, where fluid accumulates in the body tissues, causing swelling and weight increase. In left-sided heart failure, weight gain is not as prominent because the primary issue is the backup of blood into the lungs, not fluid retention in the tissues.

Choice C reason: A distended abdomen can occur in heart failure due to fluid accumulation; however, it is more characteristic of right-sided heart failure, where the failure of the right ventricle leads to systemic congestion, including the abdominal area. In left-sided heart failure, the primary effect is on the lungs, not the abdomen.

Choice D reason: Dyspnea, or difficulty breathing, is a hallmark symptom of left-sided heart failure. It occurs due to the backup of blood in the pulmonary circulation, which leads to pulmonary congestion and reduced oxygen exchange. Patients may experience shortness of breath, especially during exertion or when lying flat (orthopnea), and may wake up at night with shortness of breath (paroxysmal nocturnal dyspnea).

Left-sided heart failure, often caused by conditions like valvular heart disease, leads to a decrease in the heart’s ability to pump blood effectively. This results in a buildup of pressure in the lungs, manifesting as dyspnea, which is an important symptom for nurses and other healthcare providers to recognize and manage promptly.

A. Provide oral care every 4 hours and as needed B. Position the head of the client's bed in the flat position C. Turn the client every 4 hours D. Provide humidity by maintaining moisture within the ventilator tubing

Correct Answer is A

Explanation

Choice A reason:Providing oral care every 4 hours and as needed is an evidence-based practice to lower the risk of ventilator-associated pneumonia by minimizing the buildup of bacteria in the mouth³.

Choice B reason:Positioning the head of the client's bed in the flat position is not recommended as it can increase the risk of aspiration; elevating the head of the bed to 30° to 45° is the standard practice.

Choice C reason:Turning the client every 4 hours is important for preventing pressure ulcers and improving lung function but is not the primary action for reducing pneumonia risk³.

Choice D reason:Providing humidity helps to maintain mucous membrane integrity but must be carefully managed to prevent bacterial growth and is not the primary action for reducing pneumonia risk³.

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A nurse is reviewing a client's laboratory report of arterial blood gas (ABG) findings: pH 7.28, HCO3 18, and PaCO2 36. Which of the following conditions should the nurse anticipate when interpreting these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

Correct Answer is D

Explanation

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator-associated pneumonia?

Correct Answer is A

Explanation

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A nurse is admitting a client with a history of duodenal ulcer. To determine if the client's current symptoms are related to this information, the nurse should assess the client for which manifestations of a duodenal ulcer?

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