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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: This is a nonspecific finding, because a report of a severe headache can be caused by many factors, such as concussion, migraine, or tension. A headache alone is not an indication of a skull fracture.

Choice B reason: This is a specific finding, because clear fluid coming from the nares can indicate a cerebrospinal fluid (CSF) leak, which is a sign of a basilar skull fracture. CSF is the fluid that surrounds and protects the brain and spinal cord, and can leak through the nose or ears if the skull is fractured.

Choice C reason: This is a nonspecific finding, because a brief change in level of consciousness can be caused by many factors, such as hypoxia, hypoglycemia, or seizure. A change in level of consciousness alone is not an indication of a skull fracture.

Choice D reason: This is a nonspecific finding, because bleeding from the top of the scalp can be caused by many factors, such as laceration, abrasion, or contusion. Bleeding from the scalp alone is not an indication of a skull fracture.

A. Maintain the client's head of the bed at 20% B. Monitor the client’s blood glucose level C. Flush the enteral feeding tube with 10 mL of cool water after each medication D. Obtain an x-ray after beginning the feeding

Correct Answer is B

Explanation

Choice A reason: Maintaining the client's head of the bed at 20% is an incorrect action, because the head of the bed should be elevated at least 30% to prevent aspiration of the feeding.

Choice B reason: Monitoring the client’s blood glucose level is a correct action, because enteral feedings can affect the blood glucose level and the client may need insulin adjustments.

Choice C reason: Flushing the enteral feeding tube with 10 mL of cool water after each medication is an incorrect action, because cool water can cause cramping and nausea. The nurse should use warm water to flush the tube and use at least 30 mL of water to prevent clogging.

Choice D reason: Obtaining an x-ray after beginning the feeding is an incorrect action, because an x-ray should be obtained before starting the feeding to confirm the placement of the tube.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an urgent care clinic is collecting data from a client who sustained a fall. Which of the following findings should the nurse identify as an indication of a skull fracture?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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