A nurse is admitting a client who has status asthmaticus. The client's ABG results are Ph:7.31, Pa02:74mm Hg, PaC02: 56 mmHg and HCO-3: 26mEq/L The nurse should interpret these laboratory values as which of the following imbalances?

Metabolic alkalosis

Respiratory acidosis

Metabolic acidosis

Respiratory alkalosis

Answer and Explanation

The Correct Answer is B

The pH value is less than the normal range of 7.35-7.45, indicating acidosis. The PaCO2 value is elevated above the normal range of 35-45 mmHg, indicating respiratory acidosis. The PaO2 value is lower than normal, but not significantly low enough to indicate hypoxemia. The HCO3- level is within the normal range, but not significantly high enough to indicate metabolic compensation for respiratory acidosis.

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Correct Answer is C

Explanation

The nurse should act on the order to insert a 16 French retention catheter first. The patient's markedly distended bladder and agitated and confused state suggest acute urinary retention, which can be relieved by inserting a catheter to drain the urine. This is a priority intervention as urinary retention can lead to serious complications such as bladder rupture, hydronephrosis, and renal failure. Once the catheter is inserted and the patient's bladder is drained, the healthcare provider can order further tests such as an IVP or blood tests to assess renal function. The order for lorazepam can be addressed after the catheter is inserted and the patient's urinary retention is addressed.

A. Fluid restriction B. Administration of hypotonic IV ﬂuids C. Placement of an indwelling urinary catheter D. Administration Of action-exchange resin

Correct Answer is A

Explanation

The plan of care for a patient with hypothermia and ﬂuid volume excess would typically include measures to increase the patient's body temperature and decrease their ﬂuid volume. Therefore, option a (ﬂuid restriction) would be appropriate for this patient.

Options b (administration of hypotonic IV ﬂuids) and d (administration of ion-exchange resin) would not be appropriate because they would increase the patient's ﬂuid volume rather than decrease it.

Option c (placement of an indwelling urinary catheter) may be appropriate to closely monitor the patient's urine output, which is an important indicator of their ﬂuid status. However, this alone would not be sufficient to manage the patient's hypothermia and ﬂuid volume excess.

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A nurse is admitting a client who has status asthmaticus. The client's ABG results are Ph:7.31, Pa02:74mm Hg, PaC02: 56 mmHg and HCO-3: 26mEq/L The nurse should interpret these laboratory values as which of the following imbalances?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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