A person with a blood pH of 7.21 is considered to have which of the following?
Alkalosis
Normal blood pH
Acidosis
Hyperkalemia
The Correct Answer is C
Choice A: Alkalosis
Alkalosis occurs when the blood pH is higher than the normal range, specifically above 7.45. This condition indicates that the blood is too alkaline. Causes of alkalosis can include hyperventilation, loss of stomach acid through vomiting, or an overuse of diuretics. Since a blood pH of 7.21 is below the normal range, it does not indicate alkalosis.
Choice B: Normal Blood pH
The normal pH range for blood is between 7.35 and 7.45. This range is crucial for the body’s metabolic processes and enzyme functions. A blood pH of 7.21 is below this range, indicating an abnormal condition.
Choice C: Acidosis
Acidosis is the correct answer. It occurs when the blood pH drops below 7.35, indicating that the blood is too acidic. A pH of 7.21 is significantly below the normal range, confirming acidosis. This condition can result from various factors, including respiratory issues that lead to an accumulation of carbon dioxide or metabolic problems that increase acid production or decrease bicarbonate levels.
Choice D: Hyperkalemia
Hyperkalemia refers to an elevated level of potassium in the blood, not a change in blood pH. While hyperkalemia can be associated with acidosis, it is not defined by the pH level itself. Therefore, a blood pH of 7.21 does not directly indicate hyperkalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E","G"]
Explanation
Choice A: Bradypnea
Bradypnea, or slow breathing, is not typically associated with inadequate pain control. It is more often related to the effects of certain medications, such as opioids, or underlying respiratory conditions. Inadequate pain control is more likely to cause increased respiratory rate (tachypnea) rather than decreased.
Choice B: Irritability
This is a correct answer. Irritability can be a sign of inadequate pain control. Pain can cause significant discomfort and distress, leading to changes in mood and behavior. Patients who are in pain may become irritable, anxious, or agitated.
Choice C: Tachycardia
This is another correct answer. Tachycardia, or an increased heart rate, can be a physiological response to pain. When a patient is in pain, the body’s stress response is activated, leading to the release of stress hormones like adrenaline, which can increase heart rate.
Choice D: Hypoglycemia
Hypoglycemia, or low blood sugar, is not directly related to pain control. It is more commonly associated with diabetes management, fasting, or certain medications. While it is important to monitor blood sugar levels, hypoglycemia is not a typical indicator of inadequate pain control.
Choice E: Poor cough effort
This is a correct answer. Poor cough effort can indicate inadequate pain control, especially after chest surgery. Pain can make it difficult for patients to take deep breaths or cough effectively, which is essential for preventing respiratory complications such as pneumonia.
Choice F: Drowsiness
Drowsiness is not typically a sign of inadequate pain control. It is more often a side effect of pain medications, particularly opioids. While it is important to monitor for excessive sedation, drowsiness alone does not indicate that pain is not being adequately managed.
Choice G: Refusal to participate in physical therapy
This is the final correct answer. Refusal to participate in physical therapy can be a sign of inadequate pain control. Pain can make movement and physical activity difficult and uncomfortable, leading patients to avoid necessary rehabilitation exercises. Effective pain management is crucial for encouraging participation in physical therapy and promoting recovery.
Correct Answer is A
Explanation
Choice A: Show the caregiver how to check the patient’s temperature and blood pressure
Showing the caregiver how to check the patient’s temperature and blood pressure involves direct patient education and demonstration, which requires the clinical judgment and expertise of a licensed nurse. This task ensures that the caregiver understands the correct techniques and can accurately monitor the patient’s vital signs. Delegating this task to assistive personnel (AP) is not appropriate because it requires a higher level of skill and knowledge to teach and verify understanding.
Choice B: Give the patient a pamphlet that reinforces teaching done by the nurse
Giving the patient a pamphlet that reinforces teaching done by the nurse is a task that can be delegated to assistive personnel (AP). This action does not require clinical judgment or advanced skills. The pamphlet serves as a supplementary resource to the verbal and hands-on education provided by the nurse. It is a straightforward task that AP can perform, ensuring that the patient has access to written information that reinforces the nurse’s teaching.
Choice C: Evaluate whether the patient and caregiver understand the teaching
Evaluating whether the patient and caregiver understand the teaching is a critical component of the discharge process that requires the clinical judgment of a licensed nurse. This task involves assessing the patient’s and caregiver’s comprehension, identifying any gaps in understanding, and providing additional education as needed. It is not appropriate to delegate this responsibility to assistive personnel (AP) because it requires professional assessment skills.
Choice D: Plan topics for the discharge teaching session with the patient and caregiver
Planning topics for the discharge teaching session with the patient and caregiver involves developing a comprehensive and individualized teaching plan based on the patient’s specific needs and condition. This task requires the expertise and clinical judgment of a licensed nurse to ensure that all relevant topics are covered and that the teaching plan is tailored to the patient’s situation. Delegating this task to assistive personnel (AP) is not appropriate because it requires advanced planning and professional knowledge.
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