A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50 (7.35 to 7.45), PaCO₂ 29 mm Hg (35 to 45 mm Hg), and HCO₃ 25 mEq/L (21 to 28 mEq/L). The nurse should identify that the client has which of the following acid-base imbalances?

Respiratory acidosis

Respiratory alkalosis

Metabolic acidosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Respiratory acidosis is characterized by a low pH (below 7.35) and an elevated PaCO₂ (above 45 mm Hg). This condition occurs when there is an accumulation of carbon dioxide in the blood due to hypoventilation or impaired lung function. In this case, the client’s pH is elevated, and PaCO₂ is low, which does not align with respiratory acidosis.

Choice B Reason:

Respiratory alkalosis is indicated by a high pH (above 7.45) and a low PaCO₂ (below 35 mm Hg). This condition results from hyperventilation, which causes excessive exhalation of carbon dioxide. The client’s ABG results show a pH of 7.50 and a PaCO₂ of 29 mm Hg, consistent with respiratory alkalosis.

Choice C Reason:

Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO₃ (below 21 mEq/L). This condition occurs due to an accumulation of acids or a loss of bicarbonate in the body. The client’s pH is elevated, and HCO₃ is within the normal range, which does not indicate metabolic acidosis.

Choice D Reason:

Metabolic alkalosis is indicated by a high pH (above 7.45) and a high HCO₃ (above 28 mEq/L). This condition results from an excess of bicarbonate or a loss of acids. The client’s pH is elevated, but HCO₃ is within the normal range, which does not support a diagnosis of metabolic alkalosis.

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Correct Answer is B

Explanation

Choice A Reason

“Lie on your left side.” This statement is incorrect. After a liver biopsy, the client should lie on their right side to apply pressure to the biopsy site and help prevent bleeding.

Choice B Reason

“Lie on your right side.” This is the correct instruction. Lying on the right side helps compress the liver biopsy site, reducing the risk of bleeding and promoting clot formation.

Choice C Reason

“Increase your fluid intake.” This statement is not specifically related to post-liver biopsy care. While staying hydrated is generally good advice, it is not a primary instruction for post-biopsy care.

Choice D Reason

“Decrease your fluid intake.” This statement is incorrect. There is no need to decrease fluid intake after a liver biopsy. Proper hydration is important for overall health and recovery.

A. Maintain strict bed rest. B. Restrict fluid intake to the morning hours. C. Administer aspirin. D. Provide a low-sodium diet.

Correct Answer is D

Explanation

Choice A Reason

Maintain strict bed rest. This intervention is not typically recommended for managing Ménière’s disease. While rest during acute vertigo episodes is important, strict bed rest is not necessary and can lead to other complications such as muscle atrophy and decreased mobility.

Choice B Reason

Restrict fluid intake to the morning hours. This statement is incorrect. Fluid intake should be evenly distributed throughout the day to help manage the symptoms of Ménière’s disease. Restricting fluids to the morning hours can lead to dehydration and does not effectively manage the condition.

Choice C Reason

Administer aspirin. This intervention is not recommended for Ménière’s disease. Aspirin can worsen tinnitus, a common symptom of Ménière’s disease, and is generally avoided in these patients.

Choice D Reason

Provide a low-sodium diet. This is the correct intervention. A low-sodium diet helps reduce fluid retention in the body, which can decrease the pressure in the inner ear and help manage the symptoms of Ménière’s disease. Reducing sodium intake to 1,500-2,000 milligrams per day is often recommended.

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A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50 (7.35 to 7.45), PaCO₂ 29 mm Hg (35 to 45 mm Hg), and HCO₃ 25 mEq/L (21 to 28 mEq/L). The nurse should identify that the client has which of the following acid-base imbalances?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

Correct Answer is B

Explanation

A nurse is planning care for a client who has Ménière’s disease and is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse in a rural community is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instructions should the nurse include in the teaching?

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A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer?

A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client’s plan? (Select all that apply.)

A nurse is admitting a client who has suspected appendicitis. Which of the following findings is the nurse’s priority to report to the provider?

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