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
The Correct Answer is C
A nurse reviewing the laboratory results of a client who has DKA should identify that the client's ABG results of pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L indicate metabolic acidosis. Metabolic acidosis is an acid-base imbalance characterized by a low pH (less than 7.35) and a low bicarbonate level (less than 22 mEq/L).
The other options are not correct.
a) Respiratory alkalosis is an acid-base imbalance characterized by a high pH (greater than 7.45) and a low PaCO₂ (less than 35 mm Hg).
b) Metabolic alkalosis is an acid-base imbalance characterized by a high pH (greater than 7.45) and a high bicarbonate level (greater than 26 mEq/L).
d) Respiratory acidosis is an acid-base imbalance characterized by a low pH (less than 7.35) and a high PaCO₂ (greater than 45 mm Hg).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. "You can use an adhesive remover when changing the colostomy skin barrier."
The nurse should inform the client that they can use an adhesive remover when changing the colostomy skin barrier. Adhesive removers are helpful in gently removing the adhesive residue left behind by the previous ostomy appliance. This can make the process of changing the colostomy skin barrier more comfortable for the client and help prevent skin irritation or damage.
Explanation for the other options:
a. "You should scrub the skin around the colostomy when cleaning." Scrubbing the skin around the colostomy can be harsh and may cause skin irritation or damage. It is recommended to clean the peristomal skin gently using mild soap and water, followed by thorough drying.
c. "You will need a device to suction stool from the colostomy bag." Suctioning stool from the colostomy bag is not a routine procedure for colostomy care. Colostomy bags are designed to collect stool, and emptying the bag as needed is the appropriate method of management.
d. "You should empty the colostomy bag when it is three-fourths full." The timing of emptying the colostomy bag may vary for each individual. It is generally recommended to empty the colostomy bag when it is one-third to one-half full to prevent leakage or discomfort. The client should be educated on monitoring the bag and emptying it as necessary based on their own output and comfort level.
Correct Answer is B
Explanation
The instruction that the nurse should include is "You can take a shower 1 day after your procedure." According to the Cleveland Clinic, the morning after the procedure, the client may take the dressing off the catheter insertion site. The easiest way to do this is when showering, get the tape and dressing wet and remove it.
Option a is incorrect because there is no information suggesting that a client must wait 3 days before resuming a regular diet after a cardiac catheterization.
Option c is incorrect because according to the Cleveland Clinic, clients should gradually increase their activities until they reach their normal activity level within one week after the procedure.
Option d is incorrect because there is no information suggesting that a client must wait 1 week before returning to school after cardiac catheterization.
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