A nurse is caring for a patient who has the following arterial blood values: pH 7.12, PaO 56 mm Hg, PaCO 65 mm Hg, and HCO - 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values?
Diabetic ketoacidosis in a person with emphysema
Diarrhea for 36 hours in an older, frail woman
Anxiety-induced hyperventiIation in an adolescent
Bronchial obstruction related to aspiration of a hot dog
The Correct Answer is D
A. Diabetic ketoacidosis (DKA) in a person with emphysema:
In DKA, there is typically metabolic acidosis due to the accumulation of ketones in the blood, leading to a decrease in pH. However, the respiratory compensation mechanism in DKA usually results in a decreased PaCO2 (respiratory alkalosis) rather than an elevated PaCO2 as seen in the blood gas values provided. Additionally, emphysema is associated with chronic respiratory acidosis, not respiratory alkalosis as indicated by the elevated PaCO2.
B. Diarrhea for 36 hours in an older, frail woman:
Prolonged diarrhea can lead to metabolic acidosis due to the loss of bicarbonate through the gastrointestinal tract. The pH of 7.12 and the decreased HCO3- (22 mEq/L) suggest metabolic acidosis. However, the elevated PaCO2 (respiratory acidosis) is not consistent with pure metabolic acidosis caused by diarrhea. Respiratory acidosis typically occurs due to hypoventilation or respiratory dysfunction.
C. Anxiety-induced hyperventilation in an adolescent:
Anxiety-induced hyperventilation can lead to respiratory alkalosis due to excessive blowing off of CO2, resulting in a decrease in PaCO2. The pH of 7.12 is consistent with acidosis, but the elevated PaCO2 contradicts respiratory alkalosis. Anxiety-induced hyperventilation would typically result in a higher pH and lower PaCO2.
D. Bronchial obstruction related to aspiration of a hot dog:
A bronchial obstruction causing inadequate ventilation can lead to respiratory acidosis due to CO2 retention. The pH of 7.12 and the elevated PaCO2 (65 mm Hg) indicate respiratory acidosis. This situation is consistent with the blood gas values provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Elevation of the head of the bed by 30 degrees: While elevation of the head of the bed may be necessary for certain medical conditions, it is not the priority concern in a client with a gasoline burn. Decontamination and assessment of the burn injury take precedence.
B. Determining the amount of gasoline that the client encountered: While it's important to gather information about the circumstances of the injury, including the amount of gasoline involved, this is not the priority concern at the immediate moment. Decontamination and assessment of the burn take precedence over obtaining historical information.
C. Asking the client when they last ate a meal: While assessing the client's nutritional status and potential need for dietary interventions is important, it is not the priority safety concern in the context of a gasoline burn. Decontamination and assessment of the burn injury are more critical at this time.
D. Decontamination of the client
When a client sustains a gasoline burn, the priority safety concern is to decontaminate the client. Gasoline can cause chemical burns and can be absorbed through the skin, leading to systemic effects. Therefore, it's crucial to remove any remaining gasoline from the client's skin and clothing to prevent further absorption and minimize the risk of complications.
Correct Answer is D
Explanation
A. Stage III pressure injury
Stage III pressure injuries involve full-thickness skin loss, extending into the subcutaneous tissue but not through the fascia. These wounds typically present as deep craters and may involve undermining or tunneling. Non-blanchable erythema alone without visible skin loss is not characteristic of a Stage III pressure injury.
B. Stage IV pressure injury
Stage IV pressure injuries are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. These wounds often have extensive tissue damage and can be difficult to manage. Again, non-blanchable erythema without visible skin loss is not indicative of a Stage IV pressure injury.
C. Stage II pressure injury
Stage II pressure injuries involve partial-thickness skin loss with damage to the epidermis and possibly the dermis. These wounds often present as shallow open ulcers or blisters and may have characteristics such as intact or ruptured blisters. While Stage II injuries can present with erythema, non-blanchable erythema specifically indicates a Stage I injury.
D. Stage I pressure injury
Stage I pressure injuries are the earliest stage and involve non-blanchable erythema of intact skin. The skin may be warmer or cooler than surrounding tissue and may have changes in sensation. There is no visible skin loss at this stage, but the area is at risk for further injury if pressure is not relieved. Therefore, non-blanchable erythema on the heels most likely indicates a Stage I pressure injury.
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