A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial 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 make?
Metabolic acidosis
Respiratory acidosis
Metabolic alkalosis
Respiratory alkalosis
The Correct Answer is B
A. Metabolic acidosis
Metabolic acidosis is characterized by a low pH (< 7.35) and a decreased bicarbonate level (< 22 mEq/L). In this scenario, the pH is low (7.22), but the bicarbonate level is elevated (28 mEq/L), which does not support a diagnosis of metabolic acidosis.
B. Respiratory acidosis
Respiratory acidosis occurs when there is an accumulation of carbon dioxide (PaCO2 > 45 mm Hg), leading to a decrease in pH (< 7.35). In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), consistent with respiratory acidosis.
C. Metabolic alkalosis
Metabolic alkalosis is characterized by a high pH (> 7.45) and an elevated bicarbonate level (> 26 mEq/L). In this scenario, the pH is low (7.22), and the bicarbonate level is also elevated (28 mEq/L), which does not support a diagnosis of metabolic alkalosis.
D. Respiratory alkalosis
Respiratory alkalosis occurs when there is a decrease in carbon dioxide (PaCO2 < 35 mm Hg), leading to an increase in pH (> 7.45). In this case, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), which is not consistent with respiratory alkalosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fatigue
When collecting data from a client with pulmonary tuberculosis (TB), the nurse should expect to observe fatigue as one of the common manifestations. TB is a bacterial infection caused by Mycobacterium tuberculosis, primarily affecting the lungs. Fatigue is a typical symptom experienced by individuals with TB, often resulting from the body's immune response to the infection, as well as the systemic effects of inflammation and tissue damage caused by the bacteria.
B. High fever in the early morning
While fever is a symptom of tuberculosis, it may not necessarily occur specifically in the early morning. Fever associated with TB can occur at any time of the day and may persist for weeks to months. The pattern of fever can vary among individuals and may not consistently occur in the early morning.
C. Edema
Edema, or swelling due to fluid accumulation in tissues, is not typically associated with pulmonary tuberculosis. Edema is more commonly observed in conditions such as heart failure, renal failure, or liver disease, rather than in TB.
D. Increased appetite
Increased appetite is not a typical finding in pulmonary tuberculosis. In fact, individuals with active TB infection often experience appetite loss and unintended weight loss due to factors such as decreased food intake, metabolic changes, and systemic inflammation associated with the infection.
Correct Answer is ["A","C","D","E"]
Explanation
Correct Answers:
A. Frequent oral hygiene is necessary:Steroid inhalers can increase the risk of oral thrush and other infections, so maintaining good oral hygiene is essential to minimize this risk.
C. Rinse and spit after inhalation of the medication:Rinsing the mouth and spitting after using a steroid inhaler helps to remove residual medication and reduce the risk of developing oral thrush.
D. When taking a steroid drug as well as a bronchodilator, the bronchodilator should be administered first:Administering a bronchodilator first helps open the airways, allowing the steroid medication to reach deeper into the lungs for more effective treatment.
E. Hold your breath for 10 seconds during inhalation of the medication:Holding the breath allows for better medication absorption in the lungs.
Incorrect Answer:
B. The inhaler should be used on a PRN basis only:Steroid inhalers are typically used on a regular schedule for long-term control of asthma or other respiratory conditions, rather than on a PRN (as needed) basis. PRN use is more applicable to rescue inhalers, like short-acting bronchodilators.
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