A patient's arterial blood gas (ABG) results include a pH of 7.32, a PaCO2 of 56 mm Hg, and an HCO3 of 24 mEq/L. Which acid-base imbalance would the nurse use when developing the patient's plan of care?
Metabolic acidosis.
Metabolic alkalosis.
Respiratory acidosis.
Respiratory alkalosis.
The Correct Answer is C
Choice A rationale:
Metabolic acidosis is characterized by low blood pH and low bicarbonate ion levels. The patient's bicarbonate ion level (24 mEq/L) is within the normal range, and the low pH (7.32) and elevated PaCO2 (56 mm Hg) indicate respiratory acidosis, not metabolic acidosis.
Choice B rationale:
Metabolic alkalosis is characterized by high blood pH and high bicarbonate ion levels. The patient's pH is low (7.32), and the bicarbonate ion level (24 mEq/L) is within the normal range, indicating respiratory acidosis rather than metabolic alkalosis.
Choice C rationale:
Respiratory acidosis is characterized by low blood pH and high PaCO2 levels. In this case, the patient has a low pH (7.32) and elevated PaCO2 (56 mm Hg), indicating respiratory acidosis. The bicarbonate ion level (24 mEq/L) is a compensatory response. Respiratory alkalosis would present with high pH and low PaCO2 levels.
Choice D rationale:
Respiratory alkalosis is characterized by high blood pH and low PaCO2 levels. The patient's PaCO2 level is elevated (56 mm Hg), indicating respiratory acidosis, not alkalosis. The low pH (7.32) further supports the diagnosis of respiratory acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
While leukemia treatment does have severe side effects, not all of them are permanent. It is essential for the patient to be aware of potential complications but also to understand that some side effects might be temporary and can be managed with appropriate care.
Choice B rationale:
Using the call light to ask for help when getting out of bed is essential for patients receiving chemotherapy, as their immune system might be compromised, making them prone to infections and injuries. However, this information is not specific to leukemia treatment but is a general safety measure for these patients.
Choice C rationale:
Patients undergoing chemotherapy for leukemia are at an increased risk of infections due to the suppression of the immune system. Preventive measures, such as good hygiene practices and early detection of signs of infection, are crucial in managing these patients. Educating the patient about infection prevention is essential for their safety during treatment.
Choice D rationale:
Feeling isolated can be a common emotional response to any chronic illness, including leukemia. However, it is not an unavoidable consequence, and providing emotional support and involving the patient in support groups can help mitigate these feelings. This statement does not provide essential information about managing leukemia treatment.
Correct Answer is C
Explanation
Choice A rationale:
Purpura refers to purple or red discolorations on the skin caused by bleeding underneath the skin. It is larger than petechiae and ecchymosis and could be a sign of a more serious underlying condition. Petechiae are small, red or purple dots that appear on the skin due to minor bleeding from broken capillaries. In the context of leukemia and thrombocytopenia (low platelet count), petechiae are common due to impaired clotting mechanisms.
Choice B rationale:
Bruising occurs due to damage to blood vessels underneath the skin, resulting in the leakage of blood into the surrounding tissues. Bruises are typically larger than petechiae and can occur with various conditions, including trauma. In this case, the small 1-mm red macules are more indicative of petechiae.
Choice D rationale:
Ecchymosis refers to a larger area of subcutaneous bleeding or bruising. It is larger than both petechiae and purpura and often results from more significant trauma or bleeding disorders. The description of multiple 1-mm red macules is characteristic of petechiae rather than ecchymosis.
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