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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. Before, during, and after providing hygiene care, the nurse should continually assess the client's response to activity. Signs such as increased heart rate, shortness of breath, fatigue, or discomfort should be monitored closely. Assessing the client's response allows the nurse to adjust care activities as needed to prevent exacerbation of symptoms or complications.

A. Administering oxygen may be necessary if the client has respiratory compromise or if oxygen saturation levels are low during activities. However, this intervention should be based on the client's specific needs as assessed by the nurse and should not necessarily be a routine intervention

C Providing regular rest periods is an important intervention for clients with activity intolerance. However, the assessment will guide how and when these interventions should be implemented.

D. Fowler's position are also important, but the assessment will guide how and when these interventions should be implemented.

A. pH 7.45, PaCO2 35, HCO3 22 B. pH 7.25. PaCO2 61, HCO3 26 C. pH 7.23. PaCO2 27, HCO3 25 D. pH 7.54, PaCO2 59. HCO3 26

Correct Answer is B

Explanation

B. pH 7.25, PaCO2 61, HCO3 26

pH is decreased (acidosis).

PaCO2 is elevated (61 mmHg), indicating respiratory acidosis (increased CO2 retention). HCO3 is slightly elevated (26 mEq/L), compensating for the respiratory acidosis.

A. pH 7.45, PaCO2 35, HCO3 22

pH is within normal range (7.35-7.45).

PaCO2 is slightly lower than normal (35 mmHg), indicating mild respiratory alkalosis. HCO3 (bicarbonate) is within normal range (22 mEq/L).

C. pH 7.23, PaCO2 27, HCO3 25

pH is decreased (acidosis).

PaCO2 is lower than normal (27 mmHg), indicating respiratory alkalosis (which is unlikely in the context of morphine overdose with hypoventilation).

HCO3 is within normal range (25 mEq/L).

D. pH 7.54, PaCO2 59, HCO3 26

pH is increased (alkalosis).

PaCO2 is elevated (59 mmHg), indicating respiratory acidosis (consistent with hypoventilation). HCO3 is slightly elevated (26 mEq/L), compensating for the respiratory acidosis.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing for the hygiene needs of a client with an activity intolerance. Which is the priority nursing intervention?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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