Exhibits
The nurse Interprets the repeat blood gas.
Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.
The blood gas results indicate that the client has
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B","dropdown-group-3":"A"}
- The initial blood gas results show a pH of 7.21, which is below the normal range, indicating acidosis.
- The PaCO2 is elevated at 58 mmHg, suggesting that the acidosis is respiratory in nature, as CO2 is a respiratory acid.
- The HCO3 level is within the normal range, which typically would not suggest a primary metabolic problem.
- The repeat blood gas shows an improvement in pH to 7.37, which is within the normal range, indicating that the condition is being compensated.
- The PaCO2 has decreased to 52 mmHg, which is still above normal but shows improvement, further supporting the compensation.
- Given these changes, the most likely interpretation of the blood gas results is that the client has "compensated respiratory acidosis."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E","G"]
Explanation
A. Prepare to prevent respiratory or cardiac arrest: The client's decreased level of consciousness and respiratory rate of 10 breaths/minute indicate a potential risk for respiratory or cardiac arrest. Immediate measures to maintain airway patency and support ventilation may be necessary.
B. Stop infusion of magnesium: The client's decreased level of consciousness and absent deep tendon reflexes (DTR) bilaterally are signs of magnesium toxicity. Stopping the infusion of magnesium sulfate is essential to prevent further complications.
C. Increasing IV fluids is not a priority in management of magnesium toxicity.
D. Obtain serum magnesium level: With signs of magnesium toxicity, obtaining a serum magnesium level is necessary to confirm the diagnosis and guide further management.
E. Administer oxygen: The client's oxygen saturation of 93% on room air indicates hypoxemia.
Administering oxygen via nasal cannula to maintain oxygen saturation greater than 96% helps prevent further respiratory compromise.
F. Obtaining blood pressure is not a priority.
G. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium toxicity.
Since the client is showing signs of magnesium toxicity (decreased level of consciousness and absent DTRs), administering calcium gluconate is necessary to counteract the effects of magnesium
H. Caesarian delivery is not part of management for magnesium toicity.
Correct Answer is A
Explanation
A. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing: Aspirin helps inhibit platelet aggregation and is commonly administered to clients with suspected acute coronary syndrome to reduce the risk of myocardial infarction.
B. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema: While assessing extremities is important, administering aspirin takes priority in clients with suspected acute coronary syndrome.
C. Place an indwelling urinary catheter and institute strict intake and output measurements: This intervention is not indicated in the immediate management of a client with suspected acute
coronary syndrome.
D. Secure client consent for coronary angiography and percutaneous coronary intervention: While these procedures may be necessary later, the immediate priority is to administer aspirin and stabilize the client's condition.
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