A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mm Hg, and HCO3 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?
Respiratory alkalosis
Metabolic acidosis
Respiratory acidosis
Metabolic alkalosis
The Correct Answer is A
Choice A reason: This is the correct imbalance, because respiratory alkalosis is a condition that occurs when the blood pH is high, the PaCO2 is low, and the HCO3 is normal or low. Respiratory alkalosis is caused by hyperventilation, which can result from anxiety, fever, pain, or mechanical ventilation.
Choice B reason: This is an incorrect imbalance, because metabolic acidosis is a condition that occurs when the blood pH is low, the PaCO2 is normal or low, and the HCO3 is low. Metabolic acidosis is caused by the accumulation of acids in the blood, which can result from diabetic ketoacidosis, renal failure, or lactic acidosis.
Choice C reason: This is an incorrect imbalance, because respiratory acidosis is a condition that occurs when the blood pH is low, the PaCO2 is high, and the HCO3 is normal or high. Respiratory acidosis is caused by hypoventilation, which can result from airway obstruction, chest injury, or narcotic overdose.
Choice D reason: This is an incorrect imbalance, because metabolic alkalosis is a condition that occurs when the blood pH is high, the PaCO2 is normal or high, and the HCO3 is high. Metabolic alkalosis is caused by the loss of acids from the blood, which can result from vomiting, gastric suction, or diuretic therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect statement, because the client should avoid any body piercings, tattoos, or other procedures that can cause skin or mucosal trauma and increase the risk of bacterial infection and endocarditis. The client should also seek medical attention if they have a fever or other signs of infection.
Choice B reason: This is a correct statement, because the client should notify their doctor before they have dental procedures, such as cleaning, filling, or extraction, that can cause bleeding and introduce bacteria into the bloodstream. The client may need prophylactic antibiotics to prevent endocarditis.
Choice C reason: This is a partially correct statement, because the client should floss their teeth twice a day as a part of their oral care, but this is not enough to prevent recurrence of endocarditis. The client should also brush their teeth with a soft toothbrush after each meal, use an antiseptic mouthwash, and visit their dentist regularly.
Choice D reason: This is an unnecessary statement, because the client does not need to wear a mask when they go out in public, unless they have a respiratory infection or are exposed to someone who has one. Endocarditis is not transmitted by airborne or droplet routes, but by direct contact with the infected heart valves or blood.
Correct Answer is A
Explanation
Choice A reason: This is the correct action, because weighing the client before and after each dialysis treatment can help monitor the fluid balance and the effectiveness of the dialysis.
Choice B reason: This is an incorrect action, because the nurse should apply sterile gloves when handling the bags of dialysate fluid to prevent infection.
Choice C reason: This is an incorrect action, because the bags of dialysate fluid should be warmed to body temperature before instillation to prevent hypothermia and abdominal cramps.
Choice D reason: This is an irrelevant action, because checking peripheral circulation of the client's arms has no relation to peritoneal dialysis, which involves the insertion of a catheter into the abdominal cavity.
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