Exhibits

Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply

Low partial pressure of oxygen (PaO2)

Low lactic acid

Low pH

Low bicarbonate (HCO3-)

High partial pressure of carbon dioxide (PaCO2)

Answer and Explanation

Correct Answer : C,D

A. Low PaO2. Clients with DKA do not typically have significant hypoxemia unless there is concurrent respiratory compromise. The primary issue in DKA is metabolic acidosis rather than oxygenation.
B. Low lactic acid. Lactic acidosis is not a hallmark of DKA. Instead, DKA is characterized by ketone production from fatty acid metabolism. Elevated lactic acid is more common in conditions like sepsis or tissue hypoxia.
C. Low pH. Diabetic ketoacidosis (DKA) causes metabolic acidosis due to the accumulation of ketone bodies, leading to a pH below 7.35. The absence of insulin results in unregulated lipolysis and ketogenesis, significantly lowering blood pH.
D. Low bicarbonate (HCO3-). In metabolic acidosis, bicarbonate acts as a buffer and gets depleted while neutralizing excess acids. Clients with DKA typically have a bicarbonate level below 18 mEq/L (18 mmol/L), confirming metabolic acidosis.
E. High PaCO2. In metabolic acidosis, respiratory compensation leads to hyperventilation (Kussmaul respirations), causing PaCO2 to decrease as the body attempts to blow off excess CO2 to normalize pH.

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Correct Answer is C

Explanation

A. Determine patellar tendon reflex response. The patellar reflex (knee jerk) assesses function of the L2-L4 spinal nerves, which are below the level of injury (C8-T1) and do not provide information about upper extremity function. While deep tendon reflexes are important, they do not help assess function at the suspected injury level.
B. Check the urinary bladder for distention. Bladder function is controlled by the sacral spinal nerves (S2-S4), which are much lower than the injury level. While bladder dysfunction is common in spinal cord injuries, it does not assess C8-T1 nerve function specifically.
C. Ask the client to grasp an object or form a fist. The C8 and T1 spinal nerves control hand and finger movements, including grip strength. Testing the client’s ability to grasp an object or form a fist helps assess fine motor function and nerve integrity at the injury level. This is the most appropriate way to determine function in the lower cervical and upper thoracic spinal nerves.
D. Apply resistance while the client lifts the legs. Leg movement is controlled by the lumbar and sacral spinal nerves (L2-S2), which are below the injury level. Assessing leg strength does not provide relevant information about C8-T1 function.

A. Suture removal kit. B. Suction catheter. C. Sterile gauze dressing. D. Sterile piston syringe.

Correct Answer is C

Explanation

A. Suture removal kit. A suture removal kit is used when the chest tube is ready for removal, but it is not necessary to keep at the bedside during routine chest tube management. The priority is ensuring emergency supplies are available if the tube becomes dislodged.
B. Suction catheter. A suction catheter is used to remove secretions from the airway but is not essential for managing a chest tube. Chest drainage systems function independently to remove air or fluid, and routine suctioning is not required for chest tube management.
C. Sterile gauze dressing. If the chest tube accidentally dislodges, an occlusive dressing (such as sterile gauze with petroleum jelly) should be applied immediately to prevent air from re-entering the pleural space, which could lead to a tension pneumothorax. Keeping sterile gauze at the bedside ensures rapid intervention in case of accidental chest tube removal.
D. Sterile piston syringe. A sterile piston syringe is used for irrigating wounds or suctioning secretions, but it is not necessary for chest tube management. The closed drainage system should never be manually flushed unless specifically ordered by a healthcare provider.

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Exhibits Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply

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Naxlex Comprehensive Predictor Exams

A client with a gunshot wound is brought to the emergency department (ED) with a bullet entry at the spinal level of C8 and T1.The client is able to move the upper arms. To further assess the client's spinal nerve function, which action should the nurse implement?

Correct Answer is C

Explanation

A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?

Correct Answer is C

Explanation

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Patient Data Exhibits The nurse has received the arterial blood gas (ABG) results. Drag one condition and one client finding to complete the sentence(s). Based on the ABG values, the nurse knows that the client has dropdownrelated todropdown

Exhibits

Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply