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 B
Explanation
Choice A rationale:
Lying down while practicing pursed-lip breathing is not the correct instruction. Pursed-lip breathing is usually performed in a sitting or standing position. Lying down can restrict lung expansion and may not effectively support the purpose of this breathing technique, which is to improve airway pressure and reduce air trapping.
Choice B rationale:
"Exhale slowly through your mouth" is the correct instruction for pursed-lip breathing. This technique involves inhaling through the nose for a count of two and exhaling slowly and steadily through pursed lips for a count of four. The goal is to promote better exhalation, prevent airway collapse, and improve oxygen exchange. The rationale behind this choice is grounded in the mechanics of pursed-lip breathing, which helps create backpressure in the airways, maintaining them open and aiding in proper exhalation.
Choice C rationale:
Inhaling through pursed lips contradicts the proper sequence of pursed-lip breathing. The technique involves inhaling through the nose and exhaling through pursed lips. Inhaling through pursed lips would not provide the intended benefits of the technique.
Choice D rationale:
"Puff your cheeks when exhaling" is not the correct instruction. Puffing the cheeks during exhalation does not contribute to the effectiveness of pursed-lip breathing. This action could potentially impede proper exhalation and defeat the purpose of the technique, which is to control airflow and improve breathing efficiency.
Correct Answer is C
Explanation
Choice A rationale:
The neighbor is not authorized to provide consent for the client's procedure. The durable power of attorney for health care typically designates someone to make medical decisions when the client is unable to do so, but the neighbor's role may not extend to medical procedure consent.
Choice B rationale:
The client's spouse might have a legal standing to make decisions for the client, but the durable power of attorney for health care typically takes precedence over the spouse's decision-making authority in situations where it has been established.
Choice C rationale:
The provider, in this case, the medical doctor or healthcare professional performing the endoscopy, has the authority to obtain consent for the procedure. Informed consent is a crucial ethical and legal requirement, and the provider must ensure that the client or their designated decision-maker understands the procedure, its risks, and benefits before proceeding.
Choice D rationale:
A member of the facility's ethics committee does not typically have the authority to provide consent for a specific medical procedure on behalf of an incapacitated client. The ethics committee's role is to provide guidance on ethical dilemmas and issues but not to provide individual procedural consent.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today