A nurse is reviewing the ABGs of a client who has pneumonia. The nurse should identify which of the following findings is an indication of respiratory acidosis.
PaO2 86 mm Hg.
pH 7.4.
HCO3 16 mEq/L.
PaCO2 58 mm Hg.
The Correct Answer is D
Choice A rationale:
A PaO2 value of 86 mm Hg is within the normal range (80-100 mm Hg) and does not indicate respiratory acidosis. PaO2 measures the partial pressure of oxygen in arterial blood.
Choice B rationale:
A pH of 7.4 is within the normal range (7.35-7.45) and does not indicate respiratory acidosis. The pH reflects the acidity or alkalinity of the blood.
Choice C rationale:
An HCO3 (bicarbonate) level of 16 mEq/L is within the normal range (22-28 mEq/L) and does not indicate respiratory acidosis. HCO3 is a measure of the metabolic component of the body's acid-base balance.
Choice D rationale:
This is the correct choice. A PaCO2 value of 58 mm Hg is elevated and indicates respiratory acidosis. PaCO2 measures the partial pressure of carbon dioxide in arterial blood, and an elevated value suggests the presence of excess carbon dioxide, leading to acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Testicular cancer may present as a painless lump or swelling in the testicle. It's important for the client to monitor for any new or unusual lumps, as they could be indicative of cancer.
Choice B rationale:
A decreased size of the testicle is not a typical manifestation of testicular cancer. It is more commonly associated with conditions like testicular atrophy due to other causes.
Choice C rationale:
Asymmetry in the position of the testicles, with one testicle descending lower than the other, is a normal variation and not a sign of testicular cancer.
Choice D rationale:
Dilated veins above the testicle can be a sign of a varicocele, which is a separate condition from testicular cancer. It is caused by abnormal enlargement of veins in the scrotum and is generally not associated with cancer.
Correct Answer is A
Explanation
Choice A rationale:
Properly cutting the opening on the skin barrier wafer to fit over the stoma is crucial to prevent any irritation or damage to the surrounding skin. A well-fitted wafer creates a seal around the stoma, reducing the risk of stool coming into contact with the skin, which can cause excoriation.
Choice B rationale:
Emptying the bag when it is three-fourths full of stool is unrelated to the education on colostomy care. This information was provided in the previous question () and is not relevant to colostomy care education.
Choice C rationale:
The color of the stoma should not be slightly purple. A healthy stoma should be pink or red, indicating a good blood supply. A purple or dark-colored stoma could indicate inadequate blood flow, which is a concern and requires immediate medical attention.
Choice D rationale:
Cleansing the peristomal skin with moisturizing soap and water is not the recommended approach. The nurse should use plain water or mild, non-moisturizing soap to clean the peristomal skin, as moisturizing soap may leave a residue that affects the adhesion of the skin barrier wafer.
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