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: Sleepy, but arousing when the name is called
Feeling sleepy after receiving morphine is a common side effect. However, the fact that the client can be aroused when their name is called suggests that this is not necessarily an adverse effect.
The nurse should continue monitoring the client but may not consider this as a significant adverse reaction.

Choice B: Pain level of 6 on a scale from 0 to 10
Pain relief is one of the intended effects of morphine. Therefore, experiencing pain reduction is not an adverse effect.
The nurse would likely view this as a positive response to the medication.

Choice C: Respiratory rate of 8/min
A respiratory rate of 8 breaths per minute is significantly low and indicates respiratory depression, which is a serious adverse effect of morphine.
The nurse should be concerned about this finding and take appropriate action.

Choice D: SaO2 94%
An oxygen saturation (SaO2) level of 94% is within the normal range (usually 95% or higher). It is unlikely to be directly related to morphine administration.
While this value is not concerning, the nurse should continue monitoring the client's oxygen saturation.

A. Pain at rest B. Thin, brittle toenails C. Hanging legs D. Cool extremities

Correct Answer is A

Explanation

Choice A reason: Pain at rest is a common symptom of advanced PAD, indicating that blood flow is so reduced that the muscles are not receiving enough oxygen even when not active.

Choice B reason: Thin, brittle toenails can be a sign of PAD due to poor blood flow affecting the growth and health of the nails.

Choice C reason: Hanging legs, or dependent positioning, may temporarily relieve pain for PAD patients due to gravity assisted blood flow; however, it is not a finding but rather a coping mechanism.

Choice D reason: Cool extremities are expected in PAD because reduced blood flow decreases the warmth supplied to the tissues.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client 15 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

Correct Answer is C

Explanation

A nurse is assessing a male client who has advanced peripheral artery disease (PAD). Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

A nurse suspects a client with myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?

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?

A nurse is caring for a client who has peptic ulcer disease. The nurse should monitor the client for which of the following findings as an indication of gastrointestinal perforation?

A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for:

A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. Which of the following should the nurse use as the priority source of verification?

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?