A client is admitted to the medical-surgical unit with a chief complaint of prolonged vomiting over the past 24 hours. Based on the arterial blood gas (ABG) results of pH 7.5. PaCO2 36, HCO3 40, the nurse determines that the client is experiencing:
respiratory alkalosis.
respiratory acidosis.
metabolic acidosis.
metabolic alkalosis.
The Correct Answer is D
D. Metabolic alkalosis is characterized by an increased pH (alkalosis) and an increased HCO3. In this case, the pH is elevated (7.5), indicating alkalosis, which supports metabolic alkalosis. The HCO3 is elevated at 40 mEq/L, which further supports metabolic alkalosis. The PaCO2 is normal or slightly low (36 mmHg), which can occur as a compensatory response to metabolic alkalosis.
A. Respiratory alkalosis is characterized by an increase in pH (alkalosis) and a decrease in PaCO2 (hypocapnia). In this scenario, the pH is elevated (7.5), which indicates alkalosis. The PaCO2 is 36 mmHg, which is within the normal range (35-45 mmHg) but slightly on the lower side (slight hypocapnia). The HCO3 is elevated at 40 mEq/L, which suggests a compensatory response by the kidneys to retain bicarbonate to counteract the alkalosis.
B. Respiratory acidosis is characterized by a decrease in pH (acidosis) and an increase in PaCO2 (hypercapnia). In this case, the pH is elevated (7.5), indicating alkalosis, which contradicts respiratory acidosis. The PaCO2 is 36 mmHg, which is normal or slightly low, not high as expected in respiratory acidosis. The elevated HCO3 (40 mEq/L) suggests a compensatory metabolic response to the alkalosis, not to acidosis.
C. Metabolic acidosis is characterized by a decreased pH (acidosis) and a decreased HCO3. In this scenario, the pH is elevated (7.5), indicating alkalosis, which contradicts metabolic acidosis. The HCO3 is elevated at 40 mEq/L, indicating metabolic alkalosis rather than metabolic acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. This option correctly identifies therationale behind the nurse's instruction. Immunosuppressed clients have a weakened immune system, making them highly vulnerable to infections. Family members may carry microorganisms on their hands, clothes, or respiratory secretions that can potentially transmit infections to the client. Wearing gloves and a mask helps reduce the risk of introducing pathogens to the client.
A. This option suggests that the risk is related to hospital staff transmitting infections to family members. While this is a concern in healthcare settings, it is not directly related to the specific situation described where family members are visiting an immunosuppressed client in a protective environment.
B. This option implies that the hospital environment itself poses a risk of infection transmission to family members. While hospitals can harbor various pathogens, the primary concern in this scenario is the transmission of infections to the immunosuppressed client from outside sources, including family members.
D. This option suggests that the client could transmit infections to family members. While this is theoretically possible depending on the specific infectious agent and the client's condition, the primary concern in a protective environment is preventing infections from entering the client's environment and affecting their health.
Correct Answer is ["A","B","C","D"]
Explanation
A. Monitoring intake (fluids taken orally or intravenously) and output (urine, vomitus, diarrhea) helps assess fluid balance and hydration status. It is essential in clients with vomiting and diarrhea to prevent dehydration or fluid overload.
B. Vomiting and diarrhea can lead to dehydration and electrolyte imbalances, which may affect the skin and oral mucosa. Providing good mouth care (e.g., oral hygiene, hydration) and skin care (e.g., gentle cleansing, moisturizing) helps maintain comfort and prevent complications such as skin breakdown.
C. This may be appropriate depending on the severity of the client's condition and the healthcare provider's orders. Daily weights help monitor fluid balance and assess for changes in hydration status. However, in acute cases of vomiting and diarrhea, more frequent weights or other assessments of fluid status may be necessary.
D. Assessing the client's level of consciousness is important to monitor for signs of dehydration or electrolyte disturbances, which can affect neurological function. Changes in level of consciousness may indicate worsening dehydration or other complications that require prompt intervention.
E. Loop diuretics are medications used to increase urine output by inhibiting sodium reabsorption in the kidneys. However, they are not indicated for treating vomiting and diarrhea. In fact, administering diuretics could exacerbate fluid and electrolyte imbalances in a client who is already experiencing fluid loss through vomiting and diarrhea
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