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 C
Explanation
To elicit the Moro reflex, the nurse should clap hands after laying the newborn on a flat surface. The Moro reflex, also known as the startle reflex, is an involuntary motor response that infants develop shortly after birth. Loud noises and sudden movements can trigger a baby’s Moro reflex.
Option a is incorrect because turning the newborn's head quickly to one side while they are sleeping may not elicit the Moro reflex.
Option b is incorrect because placing a finger in the newborn's palm may elicit the grasp reflex, not the Moro reflex.
Option d is incorrect because holding the newborn upright with one foot touching the crib surface may not elicit the Moro reflex.
Correct Answer is A
Explanation
A nurse admitting a client who has active tuberculosis should place the client in a room that is ventilated to
the outside. This is an appropriate nursing intervention to prevent the spread of tuberculosis to others.
The other options are not correct.
b) The nurse does not need to wear a gown when delivering the client's food tray but should wear a mask and gloves.
c) Visitors are not prohibited while the client's infection is activebut should be limited and should wear masks.
d) A tuberculin skin test is not necessary prior to discharge as the client has already been diagnosed with active tuberculosis.
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