An unresponsive client was brought to the emergency room and had an arterial blood gas drawn. Ten minutes later, the laboratory calls with the following results: PaO2 74%, pH 7.22, PaCO2 85 mm Hg, and HCO3 23 mEq/L. The nurse interprets the results as indicating which imbalance?

Respiratory acidosis without compensation

Metabolic acidosis with full compensation

Respiratory acidosis with partial compensation

Metabolic acidosis without compensation

Answer and Explanation

The Correct Answer is C

A. Respiratory acidosis without compensation: The pH of 7.22 indicates acidosis, but the HCO3 level of 23 mEq/L suggests that compensation is occurring because the HCO3 is within the normal range for respiratory acidosis.
B. Metabolic acidosis with full compensation: The high PaCO2 level is more indicative of respiratory issues, not metabolic acidosis. Additionally, compensation for metabolic acidosis would show elevated HCO3.
C. Respiratory acidosis with partial compensation: The elevated PaCO2 and low pH indicate respiratory acidosis. The normal HCO3 level suggests partial compensation by the kidneys.
D. Metabolic acidosis without compensation: The elevated PaCO2 and normal HCO3 suggest respiratory acidosis rather than metabolic acidosis.

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Correct Answer is D

Explanation

A. Deep breathing and coughing exercises daily: These are important for preventing respiratory complications but do not specifically address the prevention of thrombosis.
B. Removal of compression stockings at night: Compression stockings should generally be worn continuously to prevent venous stasis and thrombosis.
C. Floating the heels while lying in bed: This helps prevent pressure ulcers but is not a primary intervention for preventing thrombosis.
D. Leg exercises ten times per hour while awake: This is the correct choice. Regular leg exercises improve circulation and help prevent venous stasis, thereby reducing the risk of thrombosis.

A. Absence of the client's gag reflex B. The client has a respiratory rate of eight (8) C. Loss of sensation at the 5th lumbar space D. The blood pressure is within 20% of the client's baseline

Correct Answer is B

Explanation

A. Absence of the client's gag reflex: This finding is not typically related to spinal anesthesia complications. The gag reflex is more pertinent to general anesthesia and its effects on the brainstem.
B. The client has a respiratory rate of eight (8): This is the correct choice. A low respiratory rate (bradypnea) could indicate significant complications from spinal anesthesia, such as respiratory depression, especially if the anesthesia affects the muscles involved in respiration.
C. Loss of sensation at the 5th lumbar space: This could be a normal effect of spinal anesthesia if the level of anesthesia was intended to cover this area, but it does not necessarily indicate a complication.
D. The blood pressure is within 20% of the client's baseline: A slight change in blood pressure within this range is generally not considered a severe complication of spinal anesthesia. Significant hypotension or instability would be more concerning.

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An unresponsive client was brought to the emergency room and had an arterial blood gas drawn. Ten minutes later, the laboratory calls with the following results: PaO2 74%, pH 7.22, PaCO2 85 mm Hg, and HCO3 23 mEq/L. The nurse interprets the results as indicating which imbalance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombosis?

Correct Answer is D

Explanation

Which assessment data indicate the postoperative client who had spinal anesthesia is suffering a complication of the anesthesia?

Correct Answer is B

Explanation

After having an intravenous (IV) line in place for 72 hours, a client complains of tenderness, burning, and swelling. Assessment of the IV site reveals a cord-like vein and a reddened streak. The nurse identifies that these findings indicate what complication?

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The nurse is taking a medication history of a client scheduled for surgery the next morning. Which medication requires the nurse to immediately notify the surgeon?

To promote effective coughing, deep breathing, and ambulation in the postoperative client, what nursing action is most important?

The client is admitted with a serum sodium level of 110 mEq/L. What nursing intervention should be implemented?