A nurse is reviewing the arterial blood gas values for a client. The nurse should recognize that the values indicate which of the following acid-base imbalances?

The values are:

pH: 7.56

PaCO2: 55 mmHg

HCO3: 33 mEq/L

Normal ranges:

pH: 7.35-7.45

PaCO2: 35-45 mmHg

HCO3: 22-28 mEq/L

Metabolic Alkalosis

Metabolic Acidosis

Respiratory Alkalosis

Respiratory Acidosis

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Metabolic Alkalosis is correct. The pH of 7.56 is above the normal range (7.35-7.45), indicating alkalosis. The HCO3 level of 33 mEq/L is also above the normal range (22-28 mEq/L), which suggests a metabolic cause. In metabolic alkalosis, the body has an excess of bicarbonate or a loss of hydrogen ions.

Choice B Reason:

Metabolic Acidosis is incorrect. Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO3 level (below 22 mEq/L). The given values indicate alkalosis, not acidosis.

Choice C Reason:

Respiratory Alkalosis is incorrect. Respiratory alkalosis is characterized by a high pH (above 7.45) and a low PaCO2 (below 35 mmHg). In this case, the PaCO2 is elevated (55 mmHg), which does not align with respiratory alkalosis.

Choice D Reason:

Respiratory Acidosis is incorrect. Respiratory acidosis is characterized by a low pH (below 7.35) and a high PaCO2 (above 45 mmHg). While the PaCO2 is elevated, the pH indicates alkalosis, not acidosis.

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Correct Answer is C

Explanation

Choice A Reason:

Place suction equipment at the bedside is incorrect. While having suction equipment available is important for emergency situations, it does not directly prevent postoperative pulmonary complications. Suction equipment is used to clear the airway if the client has difficulty breathing or if there is an obstruction.

Choice B Reason:

Administer a prophylactic expectorant is incorrect. Prophylactic expectorants can help in managing secretions, but they are not the primary intervention for preventing postoperative pulmonary complications. The main goal is to promote lung expansion and prevent atelectasis.

Choice C Reason:

Encourage the use of an incentive spirometer is correct. Using an incentive spirometer encourages deep breathing and lung expansion, which helps prevent atelectasis and other postoperative pulmonary complications. It is a key intervention in postoperative care to maintain optimal lung function.

Choice D Reason:

Perform range of motion exercises is incorrect. While range of motion exercises are important for preventing musculoskeletal complications and promoting circulation, they do not directly prevent pulmonary complications. The focus for pulmonary health is on lung expansion and clearing secretions.

A. The pads will keep the staff from workplace injuries such as a pulled muscle. B. The pads will absorb any urinary incontinence and contain stool. C. The pads will help prevent friction and shearing when repositioning the client. D. The pads will prevent the client from being diaphoretic.

Correct Answer is C

Explanation

Choice A reason: While lift pads can help reduce the risk of workplace injuries for staff, such as pulled muscles, this is not their primary purpose. The main goal of using lift pads is to protect the client from injury during repositioning. Lift pads distribute the client’s weight more evenly, making it easier for staff to move them without straining themselves.

Choice B reason: Lift pads are not designed to absorb urinary incontinence or contain stool. There are specific products like incontinence pads and briefs for managing urinary and fecal incontinence. Lift pads are primarily used to assist with the safe repositioning of immobile clients.

Choice C reason: The primary purpose of lift pads is to help prevent friction and shearing when repositioning the client. Friction and shearing can cause skin damage and pressure ulcers, especially in immobile clients. Lift pads reduce the risk of these injuries by allowing smoother and safer movements.

Choice D reason: Lift pads do not prevent clients from being diaphoretic (sweating excessively). Diaphoresis can be managed through other means, such as adjusting room temperature, using fans, or providing appropriate clothing and bedding. Lift pads are not intended for this purpose.

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A nurse is reviewing the arterial blood gas values for a client. The nurse should recognize that the values indicate which of the following acid-base imbalances? The values are: pH: 7.56 PaCO2: 55 mmHg HCO3: 33 mEq/L Normal ranges: pH: 7.35-7.45 PaCO2: 35-45 mmHg HCO3: 22-28 mEq/L

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a postoperative client. Which intervention should the nurse identify as important to prevent postoperative pulmonary complications?

Correct Answer is C

Explanation

A nurse is providing an in-service about repositioning clients and the use of lift pads for immobile clients. What is the rationale for placing lift pads under an immobile client?

Correct Answer is C

Explanation

A nurse is confirming with the client the informed consent signed earlier that day. The client then states, “I have changed my mind and do not want to have the procedure done.” What action should the nurse take?

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A nurse is caring for a client who will be placed on strict bed rest after surgery. The nurse should educate the client on the use of an incentive spirometer. The use of an incentive spirometer would prevent which postoperative complication?

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A nurse is preparing to administer oral medications to a client. According to the Joint Commission, which are acceptable client identifiers? (Select all that apply.)

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A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which statement would the nurse identify as an indication that the client needs additional education?

A nurse is reviewing the arterial blood gas values for a client. The nurse should recognize that the values indicate which of the following acid-base imbalances?

The values are:

pH: 7.56

PaCO2: 55 mmHg

HCO3: 33 mEq/L

Normal ranges:

pH: 7.35-7.45

PaCO2: 35-45 mmHg

HCO3: 22-28 mEq/L