A nurse is reviewing the ABG results for a client. The client's results are pH 7.47, PaCO2 30 mm Hg, HCO3 25 mEq/L, and SaO2 90%. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
Metabolic acidosis.
Respiratory acidosis.
Metabolic alkalosis.
Respiratory alkalosis.
The Correct Answer is D
Choice A rationale: Metabolic acidosis would present with a pH below 7.35 and a low HCO3 level. This client's pH is elevated at 7.47, which indicates an alkalotic state rather than an acidic one.
Choice B rationale: Respiratory acidosis is characterized by a pH below 7.35 and a PaCO2 above 45 mm Hg. This client's results show the opposite: a high pH and a low PaCO2 level.
Choice C rationale: Metabolic alkalosis requires an elevated HCO3 (typically above 26 mEq/L) to be the primary cause of the high pH. Here, the HCO3 is 25 mEq/L, which is within the normal range.
Choice D rationale: Respiratory alkalosis is defined by a pH above 7.45 and a PaCO2 below 35 mm Hg. The client's pH of 7.47 and PaCO2 of 30 mm Hg perfectly fit this clinical diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choiceC. “I’ll compare the sensations I feel when I tense my muscles to what I feel when I relax them.”
Choice A rationale:While breathing normally is important during relaxation techniques, progressive muscle relaxation specifically focuses on tensing and relaxing muscle groups to recognize the difference in sensations.
Choice B rationale:Imagining a peaceful setting is more related to guided imagery or visualization techniques, not progressive muscle relaxation.
Choice C rationale:This is correct because progressive muscle relaxation involves tensing and then relaxing muscle groups to help the individual recognize the difference between tension and relaxation.
Choice D rationale:Using a series of stretches is not a part of progressive muscle relaxation; it is more related to stretching exercises or yoga.
Correct Answer is A
Explanation
The correct answer is choice A. 30° lateral.
Choice A rationale:
The 30° lateral position is recommended to reduce pressure on the client’s bony prominences. This position helps distribute the client’s weight more evenly and reduces the risk of pressure injury formation.
Choice B rationale:
The lateral semi-prone recumbent position may not be as effective in reducing pressure on bony prominences as the 30° lateral position. It could potentially increase pressure on certain areas, depending on the client’s body shape and condition.
Choice C rationale:
The supine position can increase pressure on the sacrum and heels, which are common sites for pressure injuries. Therefore, it is not the best position for a client at risk for pressure injury formation.
Choice D rationale:
The 45° supported Fowler’s position can increase pressure on the sacrum and ischial tuberosities, another common site for pressure injuries. Therefore, it is not the most effective position for reducing pressure on bony prominences for a client at risk for pressure injury formation.
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