A nurse is reviewing the following ABG results for a postoperative client: pH 7.27, PaCO2 49 mm Hg, PaO2 65 mm Hg, HCO 22 mEq/L. The nurse should interpret the findings as which of the following imbalances?

Respiratory acidosis

Metabolic acidosis

Respiratory alkalosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is A

The ABG results show a low pH (acidosis), a high PaCO2 (respiratory component), and a normal HCO3 (metabolic component). This indicates respiratory acidosis, which is caused by hypoventilation and retention of carbon dioxide.

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Free Nursing Study Resources

Correct Answer is B,A,C,D

Explanation

The nurse should first check for contraindications to tPA, such as hemorrhagic stroke, recent surgery, bleeding disorder, or uncontrolled hypertension. Then, the nurse should weigh the client to calculate the correct dose of tPA based on body weight. Next, thenurse should administer the tPA within three hours of symptom onset to improve the chances of recovery. Finally, the nurse should transfer the client to the CCU for close monitoring of vital signs, neurological status, and possible complications.

A. Describe the sensations the client will feel during the procedure. B. Reinforce the importance of lying still during the procedure. C. Administer a sedative medication. D. Determine whether the client has an allergy to local anesthetics.

Correct Answer is D

Explanation

The priority intervention for the nurse is to determine whether the client has an allergy to local anesthetics, as this could cause a serious adverse reaction during the procedure.

Thoracentesis is a minimally invasive procedure that involves inserting a needle into the pleural space to drain excess fluid or air from around the lungs. The procedure requires local anesthesia to numb the area where the needle is inserted. Therefore, it is essential to assess for any allergy to local anesthetics before proceeding with the procedure.

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A nurse is reviewing the following ABG results for a postoperative client: pH 7.27, PaCO2 49 mm Hg, PaO2 65 mm Hg, HCO 22 mEq/L. The nurse should interpret the findings as which of the following imbalances?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B,A,C,D

Explanation

A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse?

Correct Answer is D

Explanation

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