A patient's blood gases show a pH of 7.53, PCO2 of 48, and HCO3 of 36 mEq/L. The nurse realizes that the acid-base disorder this patient is demonstrating is which of the following?
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Alkalosis
Metabolic Acidosis
The Correct Answer is C
Choice A reason: Respiratory Acidosis is characterized by a low pH and a high PCO2, which is not the case here.
Choice B reason: Respiratory Alkalosis would involve a high pH and a low PCO2, which is not consistent with the patient's PCO2 level.
Choice C reason: Metabolic Alkalosis is indicated by a high pH and a high HCO3, which matches the patient's blood gas values.
Choice D reason: Metabolic Acidosis would show a low pH and a low HCO3, which is the opposite of this patient's presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A
Choice A rationale: Movement of the trachea toward the unaffected side indicates a possible tension pneumothorax, which is a life-threatening condition. This shift occurs due to the increased pressure on the affected side, pushing the trachea away. Immediate intervention is required.
Choice B rationale: Crepitus, or subcutaneous emphysema, can be a common finding around the chest tube insertion site. It indicates air leakage into the subcutaneous tissue but does not necessarily require immediate notification to the provider unless it is extensive or worsening.
Choice C rationale: Bubbling of the water in the water seal chamber with exhalation is expected and indicates that the chest tube is functioning properly by allowing air to escape from the pleural space. This is a normal finding in pneumothorax management.
Choice D rationale: The visibility of eyelets on the chest tube indicates that the tube is in the correct position within the pleural space. If the eyelets are not visible, it means the tube is not functioning correctly, but this is not as urgent as a tracheal shift.
Correct Answer is D
Explanation
Choice A reason: While blood pressure is important, hyperkalemia can cause cardiac dysrhythmias, making the pulse rate the first assessment to ensure the patient's immediate safety.
Choice B reason: Temperature is not directly affected by serum potassium levels and is not the priority in hyperkalemia.
Choice C reason: Respirations are less likely to be affected immediately by hyperkalemia compared to cardiac function.
Choice D reason: A high serum potassium level can lead to life-threatening cardiac arrhythmias, so assessing the pulse rate is the most critical initial action.
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