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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Teaching the most crucial content early in the session is an effective strategy to engage learners and ensure that they receive essential information. This approach captures their attention and provides a solid foundation for the rest of the session. It helps establish relevance and interest, keeping the learners engaged throughout the educational program.
Choice B rationale:
Assuming that learners have no prior knowledge of first aid might not be the best approach. Adult learners often come with varying levels of knowledge and experience. It's important to assess the learners' prior knowledge and adjust the content accordingly to avoid redundancy or information that is too basic for them.
Choice C rationale:
Repetition of procedures and techniques is a valuable teaching strategy. Repetition aids in retention and comprehension. Reiterating important points reinforces learning and helps participants remember critical steps in first aid procedures. Avoiding repetition can lead to incomplete understanding and retention.
Choice D rationale:
Dividing the planned program into several sessions held about 1 week apart might not be the most effective strategy for community education. Spacing the sessions too far apart could result in learners forgetting the content or losing interest. It's better to maintain a consistent schedule to ensure continuity and engagement.
Correct Answer is C
Explanation
Choice A rationale:
Positioning the client so that they are lying flat (Choice A) is not the appropriate action after evisceration. Evisceration is the protrusion of internal organs through a wound, and lying flat could potentially put pressure on the exposed organs and worsen the situation.
Choice B rationale:
Increasing the client's oral fluid intake (Choice B) is generally a good practice for postoperative care, but it is not the priority in the case of evisceration. The primary concern is protecting the exposed organs and preventing infection.
Choice C rationale:
Preparing the client for emergency surgery (Choice C) is the correct action after observing evisceration. Evisceration is a surgical emergency, and the client needs immediate medical intervention to repair the wound and secure the exposed organs.
Choice D rationale:
Applying gentle pressure to the dressed wound (Choice D) is contraindicated in the case of evisceration. Applying pressure could further damage the exposed organs and increase the risk of infection.
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