A nurse is caring for a client on the medical-surgical unit. Laboratory Results. Vital Signs - Day 1 - 1200: Temperature 100.9°F (38.2°C), Respiratory Rate 26/min, Heart Rate 109/min, Blood Pressure 89/58 mmHg, Pain Score 9/10. Day 2 - Medication Administration - 0700: Temperature: 98.6°F (37°C), Heart Rate 98/min, Respiratory Rate 20/min, Record, Pain Score: 2/10, Blood Pressure 111/62 mmHg. Nurses' Notes - Vital Signs. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Hypocalcemia.
Hypernatremia.
Hyperkalemia.
Potential Condition. Action to Take 1: Prepare to check a serum albumin level. Action to Take 2: Request a STAT ECG. Parameters to Monitor 1: Serum bicarbonate level. Parameters to Monitor 2: Intake and Output.
The Correct Answer is A
Hypocalcemia. Action to Take 1: Prepare to check a serum albumin level.
Rationale:
Hypocalcemia can be influenced by changes in serum albumin levels, as calcium may bind to albumin. Correcting calcium levels based on albumin can help determine the actual calcium status. Action to Take 2: Request a STAT ECG. Rationale: Hypocalcemia can lead to prolonged QT intervals on an electrocardiogram (ECG). A STAT ECG is necessary to assess cardiac function and detect any potential arrhythmias. Parameters to Monitor 1: Serum bicarbonate level. Rationale: Monitoring serum bicarbonate levels can help assess the client's acid-base balance and metabolic status. Abnormal bicarbonate levels may indicate metabolic disturbances. Parameters to Monitor 2: Intake and Output. Rationale: Monitoring intake and output is essential to evaluate the client's fluid balance and kidney function. Hypocalcemia can impact renal function, and assessing urine output is crucial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
PacO2 50 mm Hg. Choice A rationale:
Potassium levels are not directly related to respiratory acidosis. Potassium levels may be affected in certain conditions, but they are not specific indicators of respiratory acidosis.
Choice B rationale:
HCO3- (bicarbonate) levels may be elevated in metabolic alkalosis, not respiratory acidosis. In respiratory acidosis, the primary abnormality is an increased PacO2, not HCO3-.
Choice C rationale:
The partial pressure of carbon dioxide (PacO2) is a key parameter in diagnosing respiratory acidosis. In this case, a PacO2 of 50 mm Hg suggests hypoventilation and an excess of carbon dioxide in the blood, contributing to acidosis.
Choice D rationale:
The pH level given (pH 7.45) is within the normal range, which contradicts the diagnosis of respiratory acidosis. In respiratory acidosis, the pH would be expected to be below the normal range of 7.35-7.45 due to increased carbon dioxide levels.
Correct Answer is B
Explanation
Respiratory acidosis.
Choice A rationale:
Metabolic alkalosis occurs when there is an increase in pH and bicarbonate (HCO₃⁻) levels, which is not the case here. The pH value in this scenario is 7.22, indicating acidosis.
Choice B rationale:
Respiratory acidosis results from the retention of carbon dioxide (PaCO₂) in the blood, leading to a decrease in pH. In this case, the pH is low (7.22), and the PacO₂ is elevated (68 mm Hg), supporting the diagnosis of respiratory acidosis.
Choice C rationale:
Metabolic acidosis is characterized by a decrease in pH and bicarbonate levels, along with a possible negative base excess. However, in this scenario, the base excess is -2, which does not indicate metabolic acidosis.
Choice D rationale:
Respiratory alkalosis occurs when there is a decrease in PaCO₂, leading to an increase in blood pH. The ABG values provided (pH 7.22, PacO₂ 68 mm Hg) are not consistent with respiratory alkalosis.
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