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 B

Explanation

(A) Document the rhythm as normal: Asystole is a serious condition characterized by a flatline ECG, indicating no electrical activity in the heart. It is not a normal rhythm and requires immediate intervention.

(B) Start cardiopulmonary resuscitation (CPR): This is the most appropriate initial action. Asystole is a life-threatening condition that requires immediate intervention. The first step should be to start CPR and call for help.

(c) Prepare the patient for cardioversion: Cardioversion is typically used to treat conditions where the heart is beating irregularly (arrhythmias), but not when there is no electrical activity at all (asystole).

(D) Prepare to administer atropine: Atropine is sometimes used in the treatment of bradycardia (slow heart rate), not asystole. In the case of asystole, epinephrine is more commonly administered during resuscitation efforts.

A. "The client has developed drooping facial features." B. "The client may benefit from a neurology consult." C. "The client has a history of hypertension." D. “The client is disoriented and pupils are slow to respond to light"

Correct Answer is C

Explanation

A) "The client has developed drooping facial features":
This statement provides essential information regarding a new symptom that the client has developed, which is drooping facial features. This is crucial information for the provider to understand the current status of the client's condition. However, it's more pertinent to the assessment and current issue rather than the client's background.

B) "The client may benefit from a neurology consult":
While a neurology consult may indeed be necessary based on the client's symptoms, it falls more under the assessment and recommendation components of the SBAR communication tool. The background component should focus on providing the provider with pertinent information about the client's current condition and relevant history.

C) "The client has a history of hypertension":
This statement is the correct choice. It provides important background information about the client's medical history, which is relevant to the current situation. The history of hypertension could potentially contribute to the development of drooping facial features, as certain complications of hypertension can lead to neurological symptoms.

D) “The client is disoriented and pupils are slow to respond to light":
While disorientation and pupil response are significant clinical findings, they are not mentioned in the stem of the question. The background component of the SBAR should focus on the specific information related to the current issue, which in this case is the development of drooping facial features.

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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

Naxlex Comprehensive Predictor Exams

The nurse is sitting at the desk watching the telemetry monitors and notes a patient's rhythm suddenly shows asystole. Which action should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has hypertension and recently developed drooping facial features. When contacting the provider, which of the following statements should the nurse include as part of the background component of the SBAR communication tool?

Correct Answer is C

Explanation

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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?