The nurse reviews the arterial blood gas results of an assigned client and notes the laboratory report results

pH of 7.30, [normal pH is 7.35 to 7.45]

Paco2 of 58 mm Hg, [Normal Paco2 is 35 to 45 mm Hg]

Pao2 of 80 mm Hg. [normal is 80-100]

HCO3 of 27 mEq/L (27 mmol/L). [Normal HCO3 is 22-26]

The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis

Respiratory alkalosis

Metabolic acidosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is A

A. Respiratory acidosis: The pH is low (indicating acidosis), and the Paco₂ is elevated, which signifies that carbon dioxide retention is causing the acidosis. This pattern indicates respiratory acidosis, as the elevated HCO₃ suggests a compensatory response.

B. Respiratory alkalosis: Respiratory alkalosis would show a high pH with a low Paco₂. This is not consistent with the client’s lab results.

C. Metabolic acidosis: Metabolic acidosis would show a low pH with a low HCO₃. In this case, the HCO₃ is slightly elevated, ruling out metabolic acidosis.

D. Metabolic alkalosis: Metabolic alkalosis would show a high pH with an elevated HCO₃, which does not match the client’s results.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. The severity of the condition may correlate with pain but is not a direct measure of the individual's pain experience.

B. Vital signs can change due to pain but are not specific indicators of pain intensity or presence.

C. Nonverbal behavior can provide clues about pain but is subjective and can vary greatly between individuals.

D. Self-rating of pain is considered the most reliable indicator of pain because it reflects the individual's personal experience and perception of their pain, making it the gold standard for assessing pain intensity.

A. cold intolerance B. depression dry skin C. weakness and fatigue D. constipation E. mental alertness

Correct Answer is ["A","B","C","D"]

Explanation

A. Cold intolerance: Patients with hypothyroidism often have difficulty regulating body temperature, leading to a heightened sensitivity to cold.

B. Depression: Hypothyroidism can affect mood and cognitive function, often leading to symptoms of depression.

C. Weakness and fatigue: Low thyroid hormone levels can cause significant fatigue and muscle weakness due to a slower metabolism.

D. Constipation: A slowed metabolism can also affect gastrointestinal motility, resulting in constipation.

E. Mental alertness: This is typically not expected in hypothyroid patients. In fact, they may experience cognitive impairments, memory issues, or slowed thinking rather than mental alertness.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a pain assessment for an alert client. Which measure should the nurse recognize as the most reliable indicator of pain?

Correct Answer is D

Explanation

A nurse is receiving a patient from the emergency room (ER) with an admitting diagnosis of hypothyroid disorder. Exhibits The receiving medical-surgical nurse would expect the patient to exhibit which signs and symptoms? Select all that apply

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve II?

A nurse is caring for a client and observes that the client's urine is cloudy, has an unpleasant odor, and contains hematuria. The nurse should recognize that these findings are associated with which urinary problem?

A nurse is preparing to administer aspirin 650 mg PO every 12 hr. The amount available is aspirin 325 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available is hydrocortisone 250 mg/2 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is assessing a client's circulatory system. Which pulse site should the nurse avoid assessing bilaterally at the same time?

To assess the tympanic membrane mobility, which instrument is most appropriate for the nurse to use?

How should the nurse interpret the rhythm depicted in the image?

A nurse is assessing a client's cranial nerves. Which method should the nurse use to assess cranial nerve I?