A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

Respiratory alkalosis

Metabolic alkalosis

Respiratory acidosis

Metabolic acidosis

Answer and Explanation

The Correct Answer is C

A. Incorrect. The client does not have respiratory alkalosis because respiratory alkalosis is characterized by a low PaCO2 (less than 35 mm Hg) and a high pH (greater than 7.45).

B. Incorrect. The client does not have metabolic alkalosis because metabolic alkalosis is characterized by a high HCO3 (greater than 26 mEq/L) and a high pH (greater than 7.45).

C. Correct. The client has respiratory acidosis because respiratory acidosis is characterized by a high PaCO2 (greater than 45 mm Hg) and a low pH (less than 7.35).

D. Incorrect. The client does not have metabolic acidosis because metabolic acidosis is characterized by a low HCO3 (less than 22 mEq/L) and a low pH (less than 7.35).

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Correct Answer is D

Explanation

Choice A reason:

"I should gargle with an alcohol-based mouthwash to kill germs”. This statement is not appropriate. Using an alcohol-based mouthwash is not recommended for a client with stomatitis. Alcohol can be irritating to the already inflamed mucous membranes and may worsen the condition. Instead, the client should use a mild, non-alcohol-based mouthwash or rinse as prescribed by the healthcare provider.

Choice B option

"I should limit my intake of dairy products to prevent nausea." This statement is not appropriate. While some clients may experience nausea during radiation therapy, limiting dairy products is not specifically related to stomatitis management. The client should follow any dietary recommendations provided by the healthcare provider or a registered dietitian to address nausea or other dietary concerns.

Choice C option

"I should moisten my lips with lemon-glycerine swabs." This is incorrect because lemon-glycerine swabs can be drying and irritating to the oral mucosa, which may exacerbate stomatitis symptoms. Instead, using a gentle, non-irritating lip balm or petroleum jelly is preferred.

Choice D option

"I should use a soft-bristle toothbrush to clean my teeth after meals." This response indicates an understanding of the teaching because a soft-bristle toothbrush is gentle on the gums and oral tissues, which is important for a client with stomatitis, as it helps to minimize irritation and injury.

A. Form a committee of staff members to investigate current staffing issues. B. Provide support to staff members who are resistant to staffing changes. C. Schedule a staff meeting to present the different options to staff members. D. Give the staff members advance written notice of staffing changes.

Correct Answer is A

Explanation

A. Form a committee of staff members to investigate current staffing issues:This action is the best first step as it engages staff members directly in identifying the underlying causes of staffing difficulties. Involving staff in the problem-solving process can lead to more effective solutions and promote buy-in for any changes.

B. Provide support to staff members who are resistant to staffing changes:While supporting staff is important, this step should come after understanding the issues and gathering input. Addressing resistance without first identifying the root causes may not be effective.

C. Schedule a staff meeting to present the different options to staff members:While communication is important, presenting options without first gathering input and understanding the current issues may not address the root problems. A meeting should follow the investigation and data collection.

D. Give the staff members advance written notice of staffing changes:Notifying staff of changes is important, but it should come after the issues are investigated and a plan is formed. Implementing changes without understanding staff concerns may lead to further dissatisfaction.

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A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is undergoing radiation therapy and has stomatitis. Which of the following responses by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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