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

Answer and Explanation

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.

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Correct Answer is ["C","D","E"]

Explanation

A. “Your cholesterol levels should be monitored monthly while taking this medication”: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used to treat high blood pressure and heart failure. It does not typically affect cholesterol levels, so monthly cholesterol monitoring is not usually necessary.

B. “Make sure your diet contains a lot of potassium-rich foods.”: While a balanced diet is important for overall health, patients taking lisinopril should be cautious about consuming too much potassium. Lisinopril can increase potassium levels in the body, and consuming too many potassium-rich foods could lead to hyperkalemia, a condition characterized by high levels of potassium in the blood.

C. “Monitor your blood pressure on a regular basis.”: This is correct. Since lisinopril is used to treat high blood pressure, it’s important for patients to monitor their blood pressure regularly to ensure the medication is working effectively.

D. “Notify your doctor immediately if you become pregnant.”: This is correct. Lisinopril is not recommended during pregnancy as it can harm the unborn baby. If a patient becomes pregnant while taking lisinopril, they should notify their doctor immediately.

E. “Report the development of a persistent dry cough.”: This is correct. A persistent dry cough is a common side effect of ACE inhibitors like lisinopril. If a patient develops this symptom, they should report it to their healthcare provider.

A. Shiny, thin hairless skin on the lower extremities B. Dusky, red color of the feet when dangling C. Pitting edema D. Thickened toenails

Correct Answer is C

Explanation

(A) Re-collection of data: Re-collection of data is not the next step after planning. It might be done as part of the evaluation step or if there are significant changes in the client’s condition.

(B) Implementation: This is the most appropriate answer. After the planning step of the nursing process, the nurse moves on to the implementation step. This is where the nurse executes the interventions that were identified during the planning step.

(C) Data Collection: Data collection is typically the first step in the nursing process, where the nurse gathers information about the client’s health status. It is not the next step after planning.

(D) Evaluation: Evaluation is the final step of the nursing process. It involves assessing the client’s response to the nursing interventions and determining whether the client’s goals have been met. It is not the next step after planning.

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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?

Nursing Test Bank

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Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is C

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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?