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.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Metabolic acidosis is not the correct acid-base imbalance for the given ABG results. Metabolic acidosis is characterized by a low pH (acidic), low bicarbonate (HCO3) levels, and a compensatory decrease in the PaCO2. In the provided ABG results, the pH is elevated, and both the PaCO2 and HCO3 levels are within normal ranges.

Choice B rationale:

Respiratory acidosis is also not the correct acid-base imbalance for the given ABG results. Respiratory acidosis occurs when there is an elevation in PaCO2 due to inadequate ventilation, leading to an acidic pH. In the provided ABG results, the pH is elevated, and the PaCO2 level is within normal range.

Choice C rationale:

Metabolic alkalosis is the correct acid-base imbalance for the given ABG results. Metabolic alkalosis is characterized by an elevated pH, elevated bicarbonate (HCO3) levels, and a compensatory increase in PaCO2. In this case, the pH is higher than the normal range, the HCO3 level is elevated, and the PaCO2 is also slightly increased as the body attempts to compensate.

Choice D rationale:

Respiratory alkalosis is not the correct answer based on the provided ABG results. Respiratory alkalosis is marked by an elevated pH and a decrease in PaCO2 due to excessive ventilation. In the given ABG results, the pH is elevated, but the PaCO2 is not decreased; it's within the normal range.

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Correct Answer is A

Explanation

Choice A rationale:

When leaving a client's isolation room, the nurse should remove gloves (Choice A) first. Gloves are considered contaminated and can harbor microorganisms. Removing them first helps prevent the spread of potential pathogens to other surfaces or items while removing other personal protective equipment (PPE).

Choice B rationale:

Goggles (Choice B) protect the eyes from splashes and airborne particles. However, they should be removed after gloves. Gloves have a higher potential for contamination due to direct contact with the client and the environment.

Choice C rationale:

Removing the gown (Choice C) should follow the removal of gloves and goggles. The gown provides a barrier against potential contaminants and should be taken off to prevent self-contamination while disrobing from other PPE.

Choice D rationale:

The mask (Choice D) should be removed last. It provides respiratory protection and prevents the nurse from inhaling airborne particles. Keeping the mask on while removing other PPE items helps maintain a barrier against potential exposure to respiratory pathogens.

A. When administering an enema, the nurse inserts the tip of the enema tube 8 cm (3.1 in). B. When caring for a client's body after death, the nurse elevates the head of the bed. C. When providing indwelling catheter care, the nurse uses a clean washcloth, soap, and water. D. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Correct Answer is D

Explanation

The correct answer is choice d. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Choice A rationale:

Inserting the tip of the enema tube 8 cm (3.1 in) is within the recommended range for adults, which is typically 7.5 to 10 cm (3 to 4 in). This action does not require intervention.

Choice B rationale:

Elevating the head of the bed when caring for a client’s body after death is a standard practice to prevent discoloration of the face and to facilitate drainage. This action does not require intervention.

Choice C rationale:

Using a clean washcloth, soap, and water for indwelling catheter care is appropriate and follows infection control guidelines. This action does not require intervention.

Choice D rationale:

Using scissors to remove the tape that secures a peripheral IV catheter is unsafe as it poses a risk of cutting the catheter or the client’s skin. This action requires intervention to ensure the nurse uses a safer method, such as using adhesive remover or gently peeling the tape away by hand.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is leaving a client's isolation room. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

Correct Answer is A

Explanation

A nurse is observing a newly licensed nurse provide client care. Which of the following actions by the newly licensed nurse requires intervention by the nurse?

Correct Answer is D

Explanation

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