A nurse is reviewing the arterial blood gas report of a client who is in metabolic acidosis. Which of the following findings should the nurse expect?

pH 7.28 (7.35 to 7.45)

PaCO2, 31 mm Hg (35 to 45 mm Hg)

HCO2 18 mEq/L (21 to 28 mEq/L)

Pa02, 85 mm Hg (72 to 100 mm Hg)

Answer and Explanation

The Correct Answer is A

A) pH 7.28 (7.35 to 7.45): In metabolic acidosis, the pH is typically below the normal range, which is 7.35 to 7.45. A pH of 7.28 indicates acidemia, which is consistent with metabolic acidosis.

B) PaCO2, 31 mm Hg (35 to 45 mm Hg): In metabolic acidosis, the PaCO2 level may be decreased as a compensatory mechanism by the lungs to expel more carbon dioxide and counteract the acidosis. However, a PaCO2 of 31 mm Hg is slightly low but not a direct indicator of metabolic acidosis; it reflects respiratory compensation rather than the primary problem.

C) HCO3 18 mEq/L (21 to 28 mEq/L): In metabolic acidosis, the bicarbonate (HCO3) level is usually low, as it is the primary buffer that decreases in response to the acidosis. An HCO3 of 18 mEq/L is lower than the normal range, indicating a decrease consistent with metabolic acidosis.

D) PaO2, 85 mm Hg (72 to 100 mm Hg): The PaO2 level, which measures oxygen in the blood, is generally not directly affected by metabolic acidosis. While the PaO2 of 85 mm Hg is within the normal range and does not specifically indicate metabolic acidosis, it is more relevant to assessing oxygenation rather than the acid-base balance.

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Correct Answer is A

Explanation

A) Pallor in the affected extremity:
Pallor in the affected extremity is a critical finding that indicates potential compromised blood flow to the area, which can be a sign of graft failure, arterial occlusion, or inadequate perfusion. This requires immediate evaluation by the healthcare provider to prevent serious complications such as limb ischemia or loss.

B) Urine output 150 ml over 4 hr:
While low urine output can be concerning, a urine output of 150 ml over 4 hours may not be immediately alarming unless there are other symptoms of acute kidney injury or dehydration. This would need to be monitored, but it is less urgent compared to signs of compromised blood flow.

C) Temperature of 37.9° C (100.2°F):
A temperature of 37.9°C (100.2°F) is mildly elevated and may indicate a low-grade fever, which can occur postoperatively due to various reasons, including inflammatory responses. It is not as immediately critical as signs of impaired perfusion.

D) Bruising around the incisional site:
Bruising around the incisional site is a common postoperative finding and typically not immediately concerning unless it is associated with significant bleeding or signs of hematoma formation. It should be monitored but does not generally require immediate reporting unless accompanied by other alarming symptoms.

A. Use chemical restraints at bedtime. B. Use a bed alarm. C. Move client to a double room. D. Encourage participation in activities that provide excessive stimulation.

Correct Answer is B

Explanation

A) Use chemical restraints at bedtime:
Using chemical restraints, such as sedative medications, to manage wandering behavior in clients with dementia should be avoided due to potential side effects and ethical concerns. Chemical restraints can increase the risk of falls, confusion, and other adverse effects, and should only be considered as a last resort under strict medical supervision.

B) Use a bed alarm:
A bed alarm is a practical and non-invasive intervention to help monitor a client with dementia who has a history of wandering. The alarm alerts staff when the client attempts to leave the bed, allowing for immediate response to prevent wandering and potential injury. This method promotes safety while respecting the client’s autonomy.

C) Move client to a double room:
Moving a client with dementia to a double room might not be beneficial and could potentially increase confusion and agitation. Sharing a room with another client might not address the issue of wandering and could disrupt both clients' rest and well-being. A more controlled environment is preferable.

D) Encourage participation in activities that provide excessive stimulation:
Encouraging activities with excessive stimulation can exacerbate agitation and restlessness in clients with dementia. It's important to engage them in calming and structured activities that promote a sense of routine and security, rather than overwhelming them with excessive stimuli which might increase the risk of wandering.

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A nurse is reviewing the arterial blood gas report of a client who is in metabolic acidosis. Which of the following findings should the nurse expect?

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