A client has the following laboratory values: a pH of 7.55, an HCO3 level of 22 mEq/L, and a PaCO2 of 30 mmHg. Which action would the nurse plan to take?
Prepare the client for IV infusion of normal saline
Perform Allen's test
Encourage the client to increase breathing
Encourage the client to slow down breathing
The Correct Answer is D
Choice A reason: This is incorrect because normal saline is not indicated for this client. Normal saline is a isotonic solution that does not alter the acid-base balance. The client has respiratory alkalosis, which is caused by hyperventilation and results in a high pH and a low PaCO2.
Choice B reason: This is incorrect because Allen's test is not relevant for this client. Allen's test is a test to assess the patency of the radial and ulnar arteries before performing an arterial blood gas (ABG) sampling or cannulation. The client already has ABG results, so there is no need to perform Allen's test.
Choice C reason: This is incorrect because increasing breathing would worsen the client's condition. Increasing breathing would cause the client to exhale more carbon dioxide, which would lower the PaCO2 and raise the pH even more. This would increase the severity of respiratory alkalosis.
Choice D reason: This is correct because slowing down breathing would help the client to correct the respiratory alkalosis. Slowing down breathing would allow the client to retain more carbon dioxide, which would increase the PaCO2 and lower the pH. This would bring the acid-base balance closer to normal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: 60 mL of urine in a 2-hour period is not very concerning for a nurse, as it is within the normal range of urine output. The average urine output for an adult is about 1 to 2 L per day, or 40 to 80 mL per hour¹.
Choice B reason: 720 mL of urine in a 24-hour period is slightly below the normal range, but not alarming. It may indicate mild dehydration or reduced fluid intake, but it is not a sign of fluid volume excess or kidney failure¹.
Choice C reason: 600 mL of urine in a 10-hour period is also within the normal range of urine output, and does not indicate any problem with fluid balance or renal function¹.
Choice D reason: 100 mL of urine in a 5-hour period is the most concerning for a nurse, as it indicates oliguria, or abnormally low urine output. Oliguria is defined as urine output less than 400 mL per day, or less than 20 mL per hour². It may be caused by acute or chronic kidney injury, urinary obstruction, shock, dehydration, or fluid volume excess². Oliguria can lead to fluid overload, electrolyte imbalance, acidosis, and uremia, and requires immediate medical attention².
Correct Answer is C
Explanation
Choice A reason: This is incorrect because 95-110 mg/dL is the normal range of serum phosphorus level in adults, not chloride. Phosphorus is an electrolyte that is involved in energy metabolism, acid-base balance, and bone formation.
Choice B reason: This is incorrect because 10-120 mEq/L is not a realistic range for any electrolyte level in the blood. The units of mEq/L indicate the concentration of ions, not the mass of the substance. The normal range of serum chloride level in adults is expressed in mEq/L, not mg/dL.
Choice C reason: This is correct because 96-106 mEq/L is the normal range of serum chloride level in adults. Chloride is an electrolyte that is important for fluid balance, acid-base balance, and nerve transmission.
Choice D reason: This is incorrect because 1.8-2.6 mEq/L is the normal range of serum magnesium level in adults, not chloride. Magnesium is an electrolyte that is important for muscle and nerve function, as well as enzyme activity.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today