The nurse is caring for a client with the following arterial blood gas (ABG) results: pH 7.32, PaCO2 33 mmHg, Pa02 88 mmHg, HCO3 16 mEg/L. The nurse would Interpret these results as:
Table 9.9 Normal Arterial Blood Gas Values |
ABG Value. Normal Value |
pH 7.35-7.45 |
PaCO2 35-45 mmHg |
HCO3- 22-25mEq/L |
Base excess -2 to +2 |
PaO2 80-95 mmHg |
SaO2 >95% |
fully compensated respiratory acidosis.
partially compensated respiratory acidosis.
uncompensated metabolic acidosis.
partially compensated metabolic acidosis.
The Correct Answer is D
A. Fully compensated respiratory acidosis: Fully compensated respiratory acidosis would involve a low pH (indicative of acidosis), elevated PaCO2 (due to impaired ventilation), and a normal HCO3 level as compensation by the kidneys. The given ABG results show metabolic acidosis with partial respiratory compensation, not respiratory acidosis.
B. Partially compensated respiratory acidosis: In respiratory acidosis, you would expect an elevated PaCO2 (not low, as seen here) and a compensatory increase in HCO3. However, the ABG results show low HCO3 and low PaCO2, indicating that this is metabolic acidosis, not respiratory acidosis.
C. Uncompensated metabolic acidosis: Uncompensated metabolic acidosis would be indicated by a low pH and low bicarbonate (HCO3), with normal PaCO2. Since the PaCO2 is low, this suggests partial respiratory compensation, making this scenario not uncompensated but partially compensated.
D. Partially compensated metabolic acidosis: To interpret these ABG results, let's break down the values:
pH 7.32 (normal range: 7.35–7.45) indicates acidosis, as it is below the normal range.
PaCO2 33 mmHg (normal range: 35–45 mmHg) is low, suggesting that respiratory compensation is occurring to counteract the acidosis. In metabolic acidosis, the lungs typically attempt to blow off CO2 to reduce acid levels, which is why PaCO2 is low here.
HCO3 16 mEq/L (normal range: 22–25 mEq/L) is low, confirming a metabolic acidosis. The low bicarbonate level is characteristic of metabolic acidosis, where the body loses too much bicarbonate or produces too much acid. PaO2 88 mmHg (normal range: 80–95 mmHg) is within the normal range and does not indicate a significant respiratory issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["56"]
Explanation
Calculate the infusion rate in mL/min.
The total volume to be infused is 500 mL.
The infusion time is 90 minutes.
The infusion rate = 500 mL / 90 minutes = 5.5556 mL/min.
Calculate the drip rate in gtt/min.
The drop factor is 10 gtt/mL.
We need to deliver 5.5556 mL/min.
To find the drip rate, we can set up a proportion:
10 gtt / 1 mL = x gtt / 5.5556 mL
Cross-multiplying:
x = 10 gtt/mL x 5.5556 mL = 55.5556 gtt
Round the answer to the nearest whole number.
56 gtt/min.
Correct Answer is C
Explanation
A. Call for the rapid response team and request a portable chest x-ray: While it is important to call for help and obtain imaging if needed, the immediate action is to address the potential pneumothorax by sealing the wound. The rapid response team and chest x-ray are necessary for further assessment, but securing the wound is the priority in the moment.
B. Turn the suction drainage system off and auscultate breath sounds: Turning off the suction drainage system and auscultating breath sounds may be part of subsequent assessment and care, but these actions are secondary to stopping the entry of air into the pleural space. Auscultating breath sounds would be important after the chest tube is secured to assess for signs of pneumothorax or other complications, but it is not the first priority.
C. Apply a sterile dressing and tape on three sides: The first priority when a chest tube becomes accidentally dislodged is to seal the wound to prevent air from entering the pleural space, which could cause a pneumothorax (collapsed lung). The correct method to seal the chest tube insertion site is to apply a sterile dressing and tape it on three sides. This technique allows air to escape from the pleural space but prevents air from entering, creating a temporary "one-way valve" effect. This is crucial in stabilizing the patient until further medical intervention can be provided. The fourth side of the dressing is left open to allow for air to escape, which helps prevent a tension pneumothorax
D. Notify the healthcare provider immediately: While notifying the healthcare provider is important, securing the wound to prevent further air entry is the immediate priority. Notifying the provider can occur after the dressing is applied. Prompt action to stabilize the chest tube site is crucial to prevent further respiratory distress or complications.
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