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 C

Explanation

The correct answer is C.

Choice A reason: Walking on the client’s right side is incorrect because the nurse should walk on the client’s left side. This is the weaker side and the side where support is most needed.

Choice B reason: Instructing the client to look down at their feet when ambulating is incorrect because the client should be instructed to look straight ahead, not down at their feet, to maintain balance and prevent falls.

Choice C reason: Have the client sit on the side of the bed for at least 60 seconds before ambulating. This allows the nurse to assess the client’s tolerance and readiness for ambulation, and it helps prevent dizziness or fainting due to orthostatic hypotension.

Choice D reason: Placing the gait belt securely around the client’s lower chest is incorrect because the gait belt should be placed around the client’s waist, not the lower chest. This provides a secure grip for the nurse and allows for safer ambulation.

A. 1 cup shredded lettuce. B. 1 cup cantaloupe. C. 1 oz tuna. D. 1 cup raspberries.

Correct Answer is B

Explanation

Choice A rationale:

1 cup of shredded lettuce is low in potassium and is not the best source of potassium for a client with heart failure. While vegetables like lettuce are generally healthy, they do not provide a significant amount of potassium.

Choice B rationale:

1 cup of cantaloupe is the best source of potassium among the given options. Cantaloupe is a fruit that contains a moderate amount of potassium. Including this fruit in the client's diet can help maintain a balanced potassium level, which is important for heart health.

Choice C rationale:

1 oz of tuna is a source of protein but is not particularly rich in potassium. While protein intake is important for overall health, other choices on the list provide more potassium, which is specifically needed for clients with heart failure.

Choice D rationale:

1 cup of raspberries is a good source of fiber and antioxidants, but it is not as rich in potassium as cantaloupe. While raspberries can be a healthy addition to the diet, they are not the best choice for addressing potassium needs in this scenario.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is planning to assist a client who has left-sided weakness to ambulate using a gait belt. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who has heart failure and a new prescription for furosemide. Which of the following foods should the nurse recommend to the client as the best source of potassium?

Correct Answer is B

Explanation

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