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The nurse reviews the arterial blood gas (ABG) results of a client and notes the results:

pH 7.46 pH units, [normal range: 7.35-7.45]

Paco2 of 30 mm Hg (30 mmol/L), [normal range: 35-45]

HCO3- of 20 mEq/L (20 mmol/L). [normal range [22-26]

When analyzing the client's ABG results, which condition would the nurse determine the client is experiencing?

Metabolic acidosis

Metabolic alkalosis

Respiratory alkalosis

Respiratory acidosis

Answer and Explanation

The Correct Answer is C

A. Metabolic acidosis would present with a low pH and low HCO3-.

B. Metabolic alkalosis would show elevated HCO3- with a normal or elevated PaCO2.

C. The elevated pH and decreased PaCO2 indicate respiratory alkalosis, likely due to hyperventilation.

D. Respiratory acidosis would involve a low pH and high PaCO2.

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Correct Answer is C

Explanation

A. The pinnae of the ears may not provide an accurate assessment for cyanosis in clients with dark skin.

B. The dorsal surface of the hand can be misleading in clients with dark skin.

C. In clients with dark skin, cyanosis is best assessed in areas where the pigmentation is less prominent, such as the oral mucosal lining.

D. The dorsal surface of the foot is not an ideal site for assessing cyanosis in this client population.

A. Patient B. Patient's roommate C. Certified Nursing Assistant (CNA) D. Nurse

Correct Answer is A

Explanation

A. The patient is the primary source of information regarding their pain tolerance, as pain is subjective and only the patient can accurately describe their experience.

B. A patient's roommate cannot reliably report on the patient's pain experience.

C. The CNA may observe signs of pain but cannot determine the patient's subjective pain tolerance.

D. The nurse can assess the patient's pain based on behaviors and reports but relies on the patient for direct information.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing for cyanosis in a client who has dark skin. Which part of the body should the nurse examine to identify cyanosis in this client?

Correct Answer is C

Explanation

When collecting data, the nurse understands which individual is the primary source of information regarding pain tolerance.

Correct Answer is A

Explanation

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