A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arteriaI blood gas (ABG) values include:

pH 7.22

PaCO2 68 mm Hg

Base excess -2

PaO2 78 mm Hg

Oxygen saturation 80%

Bicarbonate 28 mEq/L

Which of the following interpretations of the ABG values should the nurse make7

Metabolic acidosis

Respiratory acidosis

Respiratory alkalosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is B

A. Metabolic acidosis:

Metabolic acidosis is characterized by a low pH (<7.35) and a low bicarbonate level (<22 mEq/L) due to an excess of acids in the body or a loss of bicarbonate. However, in the given ABG values, the pH is low (7.22), but the bicarbonate level is elevated (28 mEq/L), which does not align with metabolic acidosis. Therefore, metabolic acidosis is not the correct interpretation in this case.

B. Respiratory acidosis:

Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) by the lungs, leading to an accumulation of CO2 in the blood and a decrease in pH. In the ABG values provided, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), indicating respiratory acidosis as the primary disturbance. This interpretation is supported by the elevated PaCO2 and the low pH, making it the correct choice based on the given data.

C. Respiratory alkalosis:

Respiratory alkalosis results from hyperventilation, leading to excessive elimination of CO2 and a decrease in PaCO2 levels. However, in the ABG values presented, the PaCO2 is elevated (68 mm Hg), which contradicts the expected decrease seen in respiratory alkalosis. Therefore, respiratory alkalosis is not the correct interpretation of the ABG values in this case.

D. Metabolic alkalosis:

Metabolic alkalosis is characterized by a high pH (>7.45) and a high bicarbonate level (>26 mEq/L) due to excessive loss of acids or an increase in bicarbonate levels. However, in the ABG values provided, the pH is low (7.22), and the bicarbonate level is elevated (28 mEq/L), which is not consistent with metabolic alkalosis. Therefore, metabolic alkalosis is not the correct interpretation based on the given data.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. Measure the depth and width of the wound. Regular assessment and documentation of the wound’s size can help track the progress of healing and effectiveness of the treatment plan.

B. Educate the client about the need for antibiotics. If an infection is present, antibiotics may be necessary. It’s important for the client to understand the purpose and proper use of these medications.

C. Consult a nutritionist for a diet plan. Good nutrition is essential for wound healing. Certain nutrients, like protein, vitamin C, and zinc, can promote wound healing.

D. Remove any non-viable tissue. Debridement, or the removal of dead (non-viable) tissue, can help promote the healing of the wound by reducing the risk of infection and allowing healthy tissue to grow.

A. There is no redness, warmth, or drainage at the insertion site. B. Drainage from the surgical site is 30 mL less than yesterday. C. The patient reports adequate pain control with medications. D. Urine is clear yellow and urine output is greater than 40 mL/hr

Correct Answer is A

Explanation

A. There is no redness, warmth, or drainage at the insertion site.

This assessment is crucial for evaluating the status of the abdominal drain site. The absence of redness, warmth, or drainage suggests that the insertion site is healing well without signs of infection or inflammation. It indicates that the drain is functioning properly and that there are no immediate complications related to the drain insertion. This assessment directly addresses the goals related to monitoring the drain site for signs of infection or dysfunction.

B. Drainage from the surgical site is 30 mL less than yesterday.

Monitoring the drainage output from the surgical site is important to assess for changes in drainage patterns. A decrease in drainage volume may indicate reduced fluid accumulation at the surgical site, potentially reflecting improved healing and decreased need for drainage. However, while this assessment is valuable, it is not as directly related to assessing the status of the drain itself or evaluating complications at the insertion site as option A.

C. The patient reports adequate pain control with medications.

Pain control is an essential aspect of postoperative care, but it is not specifically related to assessing the functionality or complications of the abdominal drain. While pain management is important for patient comfort and recovery, it does not directly address the goals related to monitoring the drain site for signs of infection, leakage, or other complications.

D. Urine is clear yellow, and urine output is greater than 40 mL/hr.

While monitoring urine output and characteristics is important for assessing renal function and hydration status, it is not directly related to assessing the abdominal drain or its complications. Clear yellow urine and adequate urine output are generally positive indicators but do not provide specific information about the functionality or status of the drain.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a chronic wound. Which of the following are wound treatments that may assist with the healing process?

Correct Answer is ["A","B","C","D"]

Explanation

A postoperative patient has an abdominal drain. What assessment by the nurse indicates that goals for the priority patient problems related to the drain are being met?

Correct Answer is A

Explanation

A nurse cares for a patient who has a deep wound that is being treated with a wet to-damp (used to be dry) dressing. Which intervention would the nurse include in this patient’s plan of care?

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A nurse evaluates the following arterial blood gas values in a patient: pH 7.48, PaO 98 mm Hg, PaCO 28 mm Hg, and HCO - 22 mEq/L (22 mmol/L). Which patient condition does the nurse correlate with these results?

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