A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mm Hg, and HCO3 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?
Respiratory alkalosis
Metabolic acidosis
Respiratory acidosis
Metabolic alkalosis
The Correct Answer is A
Choice A reason: This is the correct imbalance, because respiratory alkalosis is a condition that occurs when the blood pH is high, the PaCO2 is low, and the HCO3 is normal or low. Respiratory alkalosis is caused by hyperventilation, which can result from anxiety, fever, pain, or mechanical ventilation.
Choice B reason: This is an incorrect imbalance, because metabolic acidosis is a condition that occurs when the blood pH is low, the PaCO2 is normal or low, and the HCO3 is low. Metabolic acidosis is caused by the accumulation of acids in the blood, which can result from diabetic ketoacidosis, renal failure, or lactic acidosis.
Choice C reason: This is an incorrect imbalance, because respiratory acidosis is a condition that occurs when the blood pH is low, the PaCO2 is high, and the HCO3 is normal or high. Respiratory acidosis is caused by hypoventilation, which can result from airway obstruction, chest injury, or narcotic overdose.
Choice D reason: This is an incorrect imbalance, because metabolic alkalosis is a condition that occurs when the blood pH is high, the PaCO2 is normal or high, and the HCO3 is high. Metabolic alkalosis is caused by the loss of acids from the blood, which can result from vomiting, gastric suction, or diuretic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct information, because pursed-lip breathing can help improve gas exchange by creating positive pressure in the airways, preventing air trapping and alveolar collapse, and increasing the exhalation time.
Choice B reason: This is an incorrect information, because limiting fluid intake to 1,500 ml per day can cause dehydration and thickening of the respiratory secretions, which can impair gas exchange and increase the risk of infection.
Choice C reason: This is an incorrect information, because practicing chest breathing each day can worsen gas exchange by increasing the use of accessory muscles, decreasing the diaphragmatic excursion, and reducing the lung expansion.
Choice D reason: This is an incorrect information, because wearing home oxygen to maintain an SpO2 of at least 94% can be harmful for a client who has emphysema, as it can suppress the hypoxic drive and cause carbon dioxide retention, which can lead to respiratory acidosis and coma. The client who has emphysema should wear home oxygen to maintain an SpO2 of 88% to 92%, or as prescribed by the provider.
Correct Answer is B
Explanation
Choice A reason: This is an incorrect statement, because the client should not share razors with anyone, even if they are disposable. Razors can cause cuts and bleeding, which can transmit the HIV virus and other infections. The client should use their own personal hygiene items and dispose of them safely.
Choice B reason: This is the correct statement, because the client should clean bathroom surfaces with a bleach and water solution. Bleach is a disinfectant that can kill germs and prevent the spread of infections. The client should also wash their hands frequently and avoid contact with bodily fluids.
Choice C reason: This is an incorrect statement, because the client should not increase their intake of raw fruits and vegetables. Raw fruits and vegetables can contain bacteria, parasites, or pesticides, which can cause infections and complications in the client who has a weakened immune system. The client should wash and cook their fruits and vegetables thoroughly before eating them.
Choice D reason: This is an incorrect statement, because the client should not continue their hobby of gardening, even if they wear a mask. Gardening can expose the client to soil, dust, fungi, or insects, which can cause infections and allergies in the client who has a compromised immune system. The client should avoid activities that can increase their risk of infection.
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