The nurse obtains the following arterial blood gas results on a client: pH 7.2, PaO2 88 mmHg, PaCO2 40 mmHg, HCO3 19 mEq/L. Which acid-base imbalance is the client experiencing?
Respiratory alkalosis
Metabolic alkalosis
Respiratory acidosis
Metabolic acidosis
The Correct Answer is D
Choice A reason: Respiratory alkalosis is not the correct answer. Respiratory alkalosis is a condition where the blood pH is high (above 7.45) due to low carbon dioxide levels (below 35 mmHg) caused by hyperventilation. The client's blood pH is low (7.2) and the carbon dioxide level is normal (40 mmHg), which does not indicate respiratory alkalosis.
Choice B reason: Metabolic alkalosis is not the correct answer. Metabolic alkalosis is a condition where the blood pH is high (above 7.45) due to high bicarbonate levels (above 26 mEq/L) caused by excessive loss of acids or intake of alkali. The client's blood pH is low (7.2) and the bicarbonate level is low (19 mEq/L), which does not indicate metabolic alkalosis.
Choice C reason: Respiratory acidosis is not the correct answer. Respiratory acidosis is a condition where the blood pH is low (below 7.35) due to high carbon dioxide levels (above 45 mmHg) caused by hypoventilation. The client's blood pH is low (7.2) but the carbon dioxide level is normal (40 mmHg), which does not indicate respiratory acidosis.
Choice D reason: This is the correct answer. Metabolic acidosis is a condition where the blood pH is low (below 7.35) due to low bicarbonate levels (below 22 mEq/L) caused by excessive production or intake of acids or loss of alkali. The client's blood pH is low (7.2) and the bicarbonate level is low (19 mEq/L), which indicates metabolic acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: I will call dietary to bring you breakfast is not the best response by the nurse. This response may imply that the nurse is willing to compromise the test results or the client's safety by allowing them to eat before the test. The nurse should explain the rationale for fasting and offer the client some water or ice chips if allowed.
Choice B reason: Food may interact with the dye that is used for the test is not the best response by the nurse. This response may be partially true, but it is not specific or clear enough to justify the need for fasting. The nurse should explain that food can affect the absorption and distribution of the radioactive tracer that is injected into the bloodstream for the test, and that eating can also interfere with the quality of the images.
Choice C reason: I will ask the health care provider if the test can be rescheduled is not the best response by the nurse. This response may suggest that the nurse is not confident or knowledgeable about the test protocol or the client's condition. The nurse should explain the importance and urgency of the test and reassure the client that they will be able to eat after the test is done.
Choice D reason: The procedure is usually completed on an empty stomach is the best response by the nurse. This response is accurate and concise, and it informs the client of the standard preparation for the test. The nurse should also provide more details about the test procedure and the expected duration, and answer any questions or concerns that the client may have.
Correct Answer is B
Explanation
Choice A reason: Providing education to the client about the procedure is not the action that the nurse should implement first. This action is important, but not urgent. The nurse should prioritize the assessment and monitoring of the client's physical status and potential complications.
Choice B reason: Assessing vital signs and catheter insertion site is the action that the nurse should implement first. This action is essential to evaluate the client's hemodynamic stability and to detect any signs of bleeding, hematoma, infection, or vascular injury at the site of catheter insertion. The nurse should also check the peripheral pulses and sensation of the affected extremity.
Choice C reason: Administering fluids to provide hydration is not the action that the nurse should implement first. This action may be indicated to prevent contrast-induced nephropathy or dehydration, but it is not the priority. The nurse should first assess the client's fluid status and renal function before administering fluids.
Choice D reason: Administering the prescribed dose of aspirin and metoprolol is not the action that the nurse should implement first. This action may be indicated to prevent thrombosis or ischemia, but it is not the priority. The nurse should first assess the client's cardiac status and contraindications before administering these medications.
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