A nurse is caring for a client who has respiratory acidosis. Which of the following pH levels should the nurse expect?
pH 7.48
pH 7.50
pH 7.31
pH 7.39
The Correct Answer is C
A. pH 7.48:
A pH of 7.48 indicates alkalosis, not acidosis. Respiratory acidosis is characterized by a pH below the normal range (7.35-7.45).
B. pH 7.50:
Similar to choice A, a pH of 7.50 indicates alkalosis, not acidosis.
C. pH 7.31:
This pH value falls below the normal range (7.35-7.45), indicating acidemia. In respiratory acidosis, there is an increase in the partial pressure of carbon dioxide (PaCO2) in the blood, leading to an accumulation of carbonic acid and a decrease in pH.
D. pH 7.39:
A pH of 7.39 falls within the normal range (7.35-7.45), indicating a normal acid-base balance. It does not indicate acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
(A) Review the client's toxicology laboratory report:
While reviewing the toxicology report is important to understand any substances that may have been ingested, it is not the immediate priority compared to ensuring the client's safety.
(B) Administer the Hamilton depression scale:
Administering the Hamilton depression scale can help assess the severity of the client's depression, but immediate safety measures take precedence over assessment tools upon admission after a suicide attempt.
(C) Initiate one-to-one nursing observation:
Initiating one-to-one nursing observation is the most immediate and crucial action to ensure the client's safety. After a suicide attempt, continuous observation is essential to prevent further self-harm and ensure the client's immediate safety.
(D) Make a contract with the client for weight gain:
While addressing anorexia nervosa and making a contract for weight gain is important for the client's long-term treatment plan, it is not the first priority. Ensuring immediate safety through continuous observation is the most critical initial step.
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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