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A nurse is caring for a client who has pneumonia with dyspnea. The client's ABG results are pH 7.30, PaCO2 50 mm Hg, HCO3 26 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

Metabolic acidosis

Respiratory acidosis

Respiratory alkalosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is B

This ABG result indicates that the client has an excess of carbon dioxide (CO2) due to hypoventilation.

A. "Metabolic acidosis" is an incorrect answer because the pH is low and the HCO3 is within normal range.

C. "Respiratory alkalosis" is an incorrect answer because the pH is low and the PaCO2 is elevated.

D. "Metabolic alkalosis" is an incorrect answer because the HCO3 is within normal range, and the pH is low.

Explanation: The ABG result shows a low pH, elevated PaCO2, and normal HCO3, indicating respiratory acidosis. This condition can be caused by conditions that affect breathing, such as pneumonia, asthma, or chronic obstructive pulmonary disease (COPD).

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Correct Answer is C

Explanation

The client's right arm should be immobilized to prevent dislodgment of the central venous catheter. The Trendelenburg position is not indicated in this situation and may increase the risk of complications. Active range of motion exercises of the right arm and frequent coughing can also increase the risk of catheter dislodgment.

Choice A, placing the client in the Trendelenburg position, is not the correct answer because it is not indicated in this situation and may increase the risk of complications.

Choice B, encouraging active range of motion exercises of the right arm, is not the correct answer because it can increase the risk of catheter dislodgment.

Choice D, instructing the client to cough frequently, is not the correct answer because it can increase the risk of catheter dislodgment.

A. Review the signs of anaphylaxis with the client. B. Instruct the client to store the injector at room temperature. C. Inform the client to seek medical attention following administration of the injection. D. Have the client perform a return demonstration of the equipment.

Correct Answer is C

Explanation

The correct answer is c. Inform the client to seek medical attention following administration of the injection.

Choice A reason: Reviewing the signs of anaphylaxis with the client is important, but it’s not the priority. The client must first know what to do in case of an emergency.

Choice B reason: Instructing the client to store the injector at room temperature is a part of the storage instructions, but it’s not the immediate action to take during an anaphylactic reaction.

Choice C reason: This is the priority because anaphylaxis is a potentially life-threatening condition and even after administering epinephrine, it’s crucial to seek immediate medical attention.

Choice D reason: Having the client perform a return demonstration of the equipment is a good teaching method, but it’s not the immediate action to take when an anaphylactic reaction occurs.

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A nurse is caring for a client who has pneumonia with dyspnea. The client's ABG results are pH 7.30, PaCO2 50 mm Hg, HCO3 26 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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