A nurse is reviewing the ABG results for a client. The client's results are pH 7.47, PaCO2 30 mm Hg, HCO3 25 mEq/L, and SaO2 90%. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
Metabolic acidosis.
Respiratory acidosis.
Metabolic alkalosis.
Respiratory alkalosis.
The Correct Answer is D
Choice A rationale: Metabolic acidosis would present with a pH below 7.35 and a low HCO3 level. This client's pH is elevated at 7.47, which indicates an alkalotic state rather than an acidic one.
Choice B rationale: Respiratory acidosis is characterized by a pH below 7.35 and a PaCO2 above 45 mm Hg. This client's results show the opposite: a high pH and a low PaCO2 level.
Choice C rationale: Metabolic alkalosis requires an elevated HCO3 (typically above 26 mEq/L) to be the primary cause of the high pH. Here, the HCO3 is 25 mEq/L, which is within the normal range.
Choice D rationale: Respiratory alkalosis is defined by a pH above 7.45 and a PaCO2 below 35 mm Hg. The client's pH of 7.47 and PaCO2 of 30 mm Hg perfectly fit this clinical diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Request additional information about the caller's relationship to the client. Rationale: While understanding the caller's relationship to the client is important for confirming the legitimacy of the request, it doesn't address the core concern of maintaining client confidentiality. Sharing information with individuals solely based on their relationship can still lead to breaches in privacy.
Choice B rationale:
Provide a general update about the client's condition over the telephone. Rationale: Providing a general update over the telephone is not a secure method of maintaining client confidentiality. General updates can inadvertently disclose sensitive information and should only be communicated through secure and private channels.
Choice C rationale:
Refer the family member to the client's provider for the update. Rationale: This choice is the correct answer as it ensures that the family member receives accurate and appropriate information from the authorized source, which is the client's healthcare provider. This approach maintains the confidentiality of the client's medical information and adheres to privacy regulations.
Choice D rationale:
Encourage the family member to contact the client directly for information. Rationale: Encouraging direct contact between the family member and the client for information sharing can potentially compromise the client's privacy. The client might not want their condition disclosed to certain individuals, and it's the responsibility of the healthcare provider to ensure that sensitive information is shared appropriately and securely.
Correct Answer is D
Explanation
Choice A rationale:
Using a 5-mL syringe to flush the catheter is not the best choice. Central venous access devices typically require a larger syringe for flushing to prevent excessive pressure and potential damage to the catheter. A smaller syringe like the 5-mL syringe can create higher pressure, which could cause complications.
Choice B rationale:
Changing the site dressing and stabilization device every 24 hours is not the recommended practice. The dressing and stabilization device should be changed according to facility policy and as needed, but a rigid 24-hour schedule is not necessary and might increase the risk of infection due to unnecessary exposure.
Choice C rationale:
Expecting blood to appear in the catheter lumen after flushing is incorrect. Blood in the catheter lumen after flushing could indicate complications such as a dislodged catheter or other issues requiring immediate attention. The catheter should ideally remain patent without the presence of blood.
Choice D rationale:
This is the correct choice. Using chlorhexidine solution to clean the catheter is an evidence-based practice to prevent infection at the insertion site. Chlorhexidine has broad-spectrum antimicrobial properties and helps reduce the risk of catheter-related infections.
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