Mrs. Jamerson, who is in the post anesthesia care unit (PACU) following surgery, is difficult to arouse and demonstrates shallow breathing. The patient does not respond to any stimuli. The nurse assesses the patient and obtains arterial blood gas (ABG) measurements STAT. The ABG shows a pH of 7.10, PaCO2 of 70 mm Hg, and HCO3 of 24 mEq/L. What does this mean?

Respiratory Alkalosis Partially Compensated

Respiratory Acidosis Uncompensated

Metabolic Alkalosis Partially Compensated

Metabolic Acidosis Uncompensated

Answer and Explanation

The Correct Answer is B

Choice A reason: Respiratory Alkalosis Partially Compensated is characterized by an elevated pH over 7.45 and a PaCO2 under 35 mmHg, with a compensatory acidic HCO3 under 22 mEq/L. This does not match the patient's ABG results.

Choice B reason: Respiratory Acidosis Uncompensated is indicated by an acidic pH under 7.35 and an elevated PaCO2 over 45 mmHg, with HCO3 in the normal range of 2226 mEq/L. The patient's ABG results show a low pH and high PaCO2, which aligns with this condition.

Choice C reason: Metabolic Alkalosis Partially Compensated would show a basic pH over 7.45 and a basic HCO3 over 26 mEq/L, with a compensatory acidic PaCO2 over 45 mmHg[^10^]. The patient's ABG values do not support this diagnosis.

Choice D reason: Metabolic Acidosis Uncompensated would present with an acidic pH under 7.35 and an acidic HCO3 under 22 mEq/L, with PaCO2 in the normal range of 3545 mmHg⁸. The patient's normal HCO3 level does not indicate metabolic acidosis.

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Correct Answer is C

Explanation

Choice A reason: Offering the bedpan every 2 hours is not specifically related to preventing urinary tract infections (UTIs) and may not be necessary unless the client has other needs that require frequent toileting.

Choice B reason: Cleansing the perineum from front to back is a standard practice to prevent the spread of bacteria from the anal area to the urethra, which can reduce the risk of UTIs.

Choice C reason: Encouraging fluid intake is crucial for clients with a spinal cord injury because it helps to flush out the urinary tract, preventing the buildup of bacteria that can cause UTIs.

Choice D reason: An indwelling urinary catheter may be necessary for a client with a T4 spinal cord injury who cannot effectively empty the bladder, but it should be used with caution as it can also increase the risk of UTIs. The decision to use an indwelling catheter should be based on a thorough assessment and consideration of all other options.

A. Chest tube eyelets not visible B. Development of subcutaneous emphysema C. Presence of tidal fluctuation in the water seal chamber D. Continuous bubbling in the suction control chamber

Correct Answer is B

Explanation

Choice A reason: The visibility of chest tube eyelets is not typically a concern unless there is evidence that the tube is dislodged. In normal circumstances, the eyelets may not be visible, and this does not necessarily indicate a need for intervention.

Choice B reason: The development of subcutaneous emphysema, which is the presence of air in the subcutaneous tissue, can be a sign of a serious complication such as a pneumothorax. It requires immediate assessment and possible intervention to prevent further complications.

Choice C reason: Tidal fluctuation in the water seal chamber is a normal finding when a chest tube is in place. It indicates that the system is patent and functioning correctly as it reflects the pressure changes in the pleural space during respiration.

Choice D reason: Continuous bubbling in the suction control chamber may indicate an air leak in the system, which could be normal if the system is set to continuous suction. However, if the bubbling is vigorous and the system is not set to continuous suction, it may indicate a new air leak and require intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about the differences between a plaster cast and a synthetic cast. Which of the following information should the nurse include in the teaching?

A nurse caring for a client who has hypertension is asked about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions?

A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse an understanding of the procedure?

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point.

A nurse is teaching a client who has a new prescription for allopurinol for the treatment of gout. Which of the following instructions should the nurse include?

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

A nurse is caring for a client who has peripheral arterial disease (PAD). Which of the following symptoms should the nurse expect to find in the client?