A nurse is reviewing the laboratory results of a client who has DKA. The client's ABG results are pH 7.30, PaCO2 34 mm Hg and HCO3 21 mEq/L. The nurse should identify that these values indicate which of the following acid-base imbalances?

Respiratory alkalosis

Metabolic alkalosis

Metabolic acidosis

Respiratory acidosis

Answer and Explanation

The Correct Answer is C

A.   Respiratory alkalosis: This condition is characterized by low levels of carbon dioxide
(PaCO2) in the blood and an elevated pH. The ABG results in DKA show a low pH, ruling out respiratory alkalosis.
B.   Metabolic alkalosis: Metabolic alkalosis is characterized by high bicarbonate (HCO3) levels and an elevated pH. The ABG results in DKA show low bicarbonate levels, ruling out metabolic alkalosis.
C.   Metabolic acidosis: Metabolic acidosis is characterized by low pH and low bicarbonate (HCO3) levels. The ABG results in DKA demonstrate both low pH and low bicarbonate levels, consistent with metabolic acidosis.
D.   Respiratory acidosis: Respiratory acidosis is characterized by high carbon dioxide (PaCO2) levels and low pH. The ABG results in DKA show a normal or slightly decreased PaCO2, ruling out respiratory acidosis.

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Correct Answer is B

Explanation

A) Allowing the infant to have soft foods is not recommended immediately following surgery to protect the surgical site.

B) Maintaining elbow restraints prevents the infant from touching or injuring the repair site, which is crucial for proper healing.

C) Feeding the infant with a spoon could disrupt the surgical site and is not advised until cleared by a healthcare provider.

D) While oral hygiene is important, brushing the infant's teeth could harm the repair site; however, specific post-operative care instructions regarding oral hygiene should be provided by the healthcare provider, which may or may not include a temporary cessation of brushing.

A. Instruct the client to report the theft to the police. B. Report the possible abuse to adult protective services. C. Ask the client if there is another family member they can call for financial help. D. Restrict visitation for the client's family until discharge.

Correct Answer is B

Explanation

A. Instruct the client to report the theft to the police: While reporting theft to the police may be necessary, the immediate concern is the safety and well-being of the client, especially if financial exploitation or abuse is suspected.
B. Report the possible abuse to adult protective services: Suspected financial exploitation or abuse of an older adult should be reported to the appropriate authorities, such as adult protective services, for investigation and intervention.
C. Ask the client if there is another family member they can call for financial help: While involving other family members may be appropriate in some situations, suspected abuse or exploitation requires intervention from trained professionals.
D. Restrict visitation for the client's family until discharge: Restricting visitation should only be done if there is a clear risk to the client's safety, and it should not be the first action taken in response to suspected abuse.

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A nurse is reviewing the laboratory results of a client who has DKA. The client's ABG results are pH 7.30, PaCO2 34 mm Hg and HCO3 21 mEq/L. The nurse should identify that these values indicate which of the following acid-base imbalances?

Nursing Test Bank

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