A nurse is reviewing the ABG values of a client who has pneumonia. Which of the following findings indicates the client is developing respiratory acidosis?
PaO2 85 mmHg
pH 7.47
HCO3 25 mEq/L
PaCO2 55 mmHg
The Correct Answer is D
Choice A reason: PaO2 85 mmHg is within the normal range of 80 to 100 mmHg and does not indicate any hypoxemia or oxygen deficiency.
Choice B reason: pH 7.47 is within the normal range of 7.35 to 7.45 and does not indicate any acid-base imbalance.
Choice C reason: HCO3 25 mEq/L is within the normal range of 22 to 26 mEq/L and does not indicate any metabolic disturbance.
Choice D reason: PaCO2 55 mmHg is above the normal range of 35 to 45 mmHg and indicates respiratory acidosis, which is a condition where the lungs cannot eliminate enough carbon dioxide and the blood becomes too acidic. This can be caused by pneumonia, which can impair gas exchange and ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: This is incorrect. The Sims' position is not used for a colposcopy, which is a procedure that examines the cervix with a magnifying device. The client should be placed in the lithotomy position, which involves lying on the back with the legs spread and supported by stirrups.
Choice B: This is incorrect. The nurse should not insert a tampon following the procedure, as this can introduce bacteria and cause infection. The nurse should advise the client to use sanitary pads instead.
Choice C: This is correct. The nurse should instruct the client to avoid sexual intercourse until the cervix is healed, which can take up to a week. Sexual intercourse can cause bleeding, pain, and infection.
Choice D: This is incorrect. The nurse should not reinforce teaching that the procedure involves dilation of the cervix, as this is not true. A colposcopy does not require dilation of the cervix, unlike some other procedures such as endometrial biopsy or hysteroscopy.
Correct Answer is B
Explanation
Choice A reason: Having a bologna sandwich is not a good choice for a client who has hypertension, as bologna is a processed meat that contains high amounts of sodium and saturated fat, which can raise blood pressure and cholesterol levels.
Choice B reason: Seasoning food with vinegar is a good choice for a client who has hypertension, as vinegar is a low-sodium condiment that can add flavor and acidity to food without increasing blood pressure.
Choice C reason: Seasoning food with ketchup is not a good choice for a client who has hypertension, as ketchup is a high-sodium condiment that can increase blood pressure and fluid retention.
Choice D reason: Having canned soup is not a good choice for a client who has hypertension, as canned soup is a high-sodium food that can increase blood pressure and fluid retention. The client should choose low-sodium or homemade soup instead.
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