A nurse is reviewing laboratory results of a client. The client's ABG results are as follows: pH 7.2, HCO, 26 mEq/L, PaCO2 52 mm Hg. Which of the following acid-base imbalances should the nurse identify the client is experiencing?
Metabolic acidosis
Metabolic alkalosis
Respiratory alkalosis
Respiratory acidosis
The Correct Answer is D
A) Metabolic acidosis: In metabolic acidosis, you would expect a low pH (acidosis) with a low bicarbonate (HCO3-) level. However, the given bicarbonate level is within the normal range (22-26 mEq/L), which indicates the acidosis is not metabolic in origin.
B) Metabolic alkalosis: Metabolic alkalosis would present with a high pH (alkalosis) and an elevated bicarbonate (HCO3-) level. The pH in this case is low, indicating acidosis, and the bicarbonate level is normal, ruling out metabolic alkalosis.
C) Respiratory alkalosis: In respiratory alkalosis, you would see a high pH (alkalosis) and a low PaCO2 due to hyperventilation. The given pH is low, indicating acidosis, and the PaCO2 is elevated, which is inconsistent with respiratory alkalosis.
D) Respiratory acidosis: Respiratory acidosis is characterized by a low pH (acidosis) and an elevated PaCO2 due to hypoventilation or impaired gas exchange. The client's ABG results show a low pH (7.2), a normal bicarbonate level (26 mEq/L), and an elevated PaCO2 (52 mm Hg), indicating the client is experiencing respiratory acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Administering risperidone 25 mg IM: Administering risperidone intramuscularly is generally used for managing severe psychotic symptoms and not typically indicated for acute panic attacks. Without prior prescription or proper assessment, this action may be unsafe and inappropriate.
B) Teaching the client how to perform guided imagery: Guided imagery is an effective technique for managing anxiety over the long term, but it is not suitable for immediate relief during a severe panic attack. The client may not be able to focus or learn new techniques when experiencing extreme distress.
C) Staying with the client until the panic attack subsides: Providing immediate emotional support and reassurance by staying with the client helps reduce the intensity of the panic attack. The nurse's presence can help the client feel safer and more secure, facilitating a return to a calmer state.
D) Encouraging the client to take quick, shallow breaths: Quick, shallow breaths can exacerbate hyperventilation and increase symptoms like dizziness and lightheadedness. It is more beneficial to encourage slow, deep breathing to help regulate breathing patterns and reduce panic symptoms.
Correct Answer is D
Explanation
A) "You should remain on a clear liquid diet for 1 week after surgery.": After a laparoscopic cholecystectomy, clients do not need to remain on a clear liquid diet for a week. They can usually progress to a regular diet as tolerated, starting with light meals and avoiding fatty, greasy foods initially to prevent discomfort.
B) "Avoid showering for 1 week after surgery.": Clients are typically allowed to shower within a day or two after surgery, as long as they avoid soaking the incisions in water and follow the healthcare provider's instructions for incision care. Avoiding showering for a week is generally unnecessary and may hinder hygiene.
C) "Cleanse the incision sites with hydrogen peroxide.": Hydrogen peroxide can delay wound healing and is not recommended for routine incision care. The nurse should advise the client to cleanse the incision sites with mild soap and water and pat them dry.
D) "Apply heat to the right shoulder for pain.": Applying heat to the right shoulder can help relieve referred pain often experienced after a laparoscopic cholecystectomy due to residual gas used during the procedure. This is a common and effective method for managing postoperative discomfort.
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