A nurse is caring for a client who has acute kidney injury. The client's ABGS are:
PH:7.26
PaCO2: 30 mm Hg
HCO3: 14 mEq/L
Which of the following acid-imbalances should the nurse identify the client is experiencing?
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
The Correct Answer is D
(A) Metabolic alkalosis: This condition is characterized by a high blood pH (>7.45) and a high bicarbonate level (>26 mEq/L). The client’s pH and bicarbonate levels are both lower than normal, which rules out metabolic alkalosis.
(B) Respiratory acidosis: This condition is characterized by a low blood pH (<7.35) and a high PaCO2 level (>45 mm Hg). Although the client’s pH is low, the PaCO2 level is also low, which rules out respiratory acidosis.
(c) Respiratory alkalosis: This condition is characterized by a high blood pH (>7.45) and a low PaCO2 level (<35 mm Hg). The client’s pH is low, which rules out respiratory alkalosis.
(D) Metabolic acidosis: This condition is characterized by a low blood pH (<7.35) and a low bicarbonate level (<22 mEq/L). The client’s pH is 7.26 and bicarbonate level is 14 mEq/L, both of which are lower than normal. This indicates metabolic acidosis, which is common in clients with acute kidney injury as the kidneys are unable to excrete hydrogen ions and reabsorb bicarbonate. Therefore, the nurse should identify that the client is experiencing metabolic acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Helping the client into the shower: This task can be safely delegated to an assistive personnel (AP). The AP can help the client with activities of daily living such as showering, as long as the client is stable and does not require close monitoring.
B. Ambulating the client in the hallway: This task can also be delegated to an AP. Assisting with ambulation is within the scope of practice for an AP, provided the client is stable and there are no specific concerns that require a nurse’s assessment.
C. Measuring vital signs: While measuring vital signs is a critical task, it can be delegated to an AP. The AP can be trained to accurately measure and report vital signs. However, the nurse should review and interpret the results.
D. Removing the sternal dressing: This is the correct answer. Removing a sternal dressing after cardiac surgery is a complex task that requires a nurse’s expertise2. The nurse needs to assess the surgical site for signs of infection or complications, which is beyond the scope of practice for an AP. Therefore, this task should not be delegated and should be performed by the nurse herself
Correct Answer is ["2"]
Explanation
To find out how many aspirin tablets the nurse should administer, we can divide the prescribed dosage by the amount of aspirin per tablet:
Dosage m prescribed: 650 mg
Amount of aspirin per tablet: 325 mg/tablet
Number of tablets = Dosage prescribed / Amount of aspirin per tablet
Number of tablets = 650 mg / 325 mg/tablet = 2 (rounded to the nearest whole number)
Therefore, the nurse should administer 2 tablets.
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