A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a Paco2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
Respiratory acidosis.
Metabolic acidosis.
Metabolic alkalosis.
Respiratory alkalosis.
The Correct Answer is A
Choice A rationale:
The arterial blood gas results show a low pH (acidosis) and an elevated Paco2 (partial pressure of carbon dioxide), which indicates respiratory acidosis. This condition occurs when there is inadequate removal of carbon dioxide through ventilation, leading to an accumulation of carbonic acid in the blood and a decrease in pH.
Choice B rationale:
Metabolic acidosis would present with a low pH and a low bicarbonate (HCO3-) level, not an elevated Paco2.
Choice C rationale:
Metabolic alkalosis would present with a high pH and an elevated bicarbonate (HCO3-) level, not an elevated Paco2.
Choice D rationale:
Respiratory alkalosis would present with a high pH and a decreased Paco2, not an elevated Paco2 as seen in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
The nurse considered contraction of facial muscles as a finding of hypocalcemia because it is associated with Chvostek's sign, which indicates neuromuscular irritability due to low calcium levels.
Choice B rationale:
Complaints of fingers tingling are indicative of hypocalcemia since tingling sensations (paresthesias) in the extremities can result from decreased calcium levels affecting nerve function.
Choice C rationale:
Carpal spasm with blood pressure measurement is known as Trousseau's sign and is associated with hypocalcemia. When the blood pressure cuff is inflated above systolic pressure, it can cause tetany in the hand if the calcium levels are low.
Choice D rationale:
Asking when foot numbness would go away does not directly relate to hypocalcemia or its symptoms. It is not a finding used to come to the conclusion of hypocalcemia in this scenario.
Choice E rationale:
The heart rate being 88 and regular does not directly indicate hypocalcemia. While hypocalcemia can lead to cardiac arrhythmias, a heart rate of 88 and regular is within the normal range and not a specific finding for hypocalcemia.
Correct Answer is D
Explanation
The correct answer isd. Assess for indications of pulmonary embolism.
Choice A rationale:
Administering a sedative is not appropriate as the priority intervention. Sedatives can depress respiratory function, which is already compromised in this patient.
Choice B rationale:
Preparing for mechanical ventilation might be necessary if the patient’s condition worsens, but it is not the immediate priority. The priority is to identify the underlying cause of the symptoms.
Choice C rationale:
Massaging the calf area for tenderness is not relevant in this context. While calf tenderness can be a sign of deep vein thrombosis (DVT), which can lead to pulmonary embolism, the immediate priority is to assess for pulmonary embolism directly.
Choice D rationale:
Assessing for indications of pulmonary embolism is the priority because the patient’s symptoms (shortness of breath, chest pain, recent use of birth control pills, smoking history, and abnormal ABG values) strongly suggest a pulmonary embolism.Early identification and treatment are crucial to prevent further complications.
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