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 C

Explanation

Choice A Reason:

Remaining 1 meter (3 feet) away from the client when providing care is not sufficient to prevent the spread of tuberculosis (TB). TB is an airborne disease, and the bacteria can remain suspended in the air for several hours. Therefore, maintaining a distance alone does not provide adequate protection against inhaling the bacteria.

Choice B Reason:

Applying a surgical mask before entering the client’s room is not the most effective measure. Surgical masks are designed to protect against large droplets and splashes, but they do not provide adequate protection against airborne particles like TB bacteria. Instead, healthcare workers should use N95 respirators, which are specifically designed to filter out airborne particles.

Choice C Reason:

Ensuring the door to the client’s room is closed at all times is a critical measure in preventing the spread of TB. This action helps to contain the airborne bacteria within the room, reducing the risk of transmission to others in the healthcare facility. This is part of airborne precautions, which are essential for managing patients with active TB.

Choice D Reason:

Placing a “no visitors” sign on the client’s door can help limit the number of people exposed to the TB bacteria, but it is not the most critical action. While it is important to restrict visitors, ensuring the door is closed and using appropriate personal protective equipment (PPE) are more effective measures in controlling the spread of TB.

A. Lemonade B. Tomato soup C. Gelatin D. Black coffee

Correct Answer is C

Explanation

Choice A Reason

Lemonade is not suitable for a client with acute gastritis. Lemonade is acidic and can irritate the stomach lining, potentially worsening the symptoms of gastritis. It is important to avoid acidic foods and beverages to prevent further irritation.

Choice B Reason

Tomato soup is also not recommended for a client with acute gastritis. Tomatoes are acidic and can exacerbate gastritis symptoms. Foods that are low in acidity are better choices for individuals with this condition.

Choice C Reason

Gelatin is the correct choice. It is bland, non-acidic, and easy to digest, making it suitable for someone recovering from acute gastritis. Gelatin can help soothe the stomach lining without causing irritation.

Choice D Reason

Black coffee should be avoided by clients with acute gastritis. Coffee is acidic and can irritate the stomach lining, leading to increased discomfort and symptoms. Caffeine can also stimulate acid production, which is not ideal for someone with gastritis.

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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 has active tuberculosis. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has acute gastritis and is NPO. The client has a new prescription to resume oral intake. Which of the following items should the nurse offer the client?

Correct Answer is C

Explanation

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.)

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A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching?

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