For an arterial blood gas (ABG) to have full compensation, which of the following statements is correct?
pCO2 and pHCO3 and pH are abnormal but the pa02 remains between 80-100 mmHg
arterial pH & pCO2 are abnormal but the pHCO3 is starting to change
pCO2, pHCO3 and pH have adjusted in expected range in 72 hours
arterial pH is between 7.35-7.45 and the pCO2 & pO2 are abnormal
The Correct Answer is C
C. Full compensation typically occurs within 2 to 3 days (approximately 72 hours) after the onset of an acid-base disturbance. During full compensation, the primary acid-base disorder (e.g., respiratory acidosis or alkalosis, metabolic acidosis or alkalosis) is still present, but the compensatory mechanisms have effectively brought the pH, pCO2, and bicarbonate (pHCO3) levels back towards normal range.
A. Full compensation occurs when both the primary disorder (respiratory or metabolic) and the compensatory mechanism (renal or respiratory) are functioning to return the pH towards normal. In this option, while the pO2 is within the normal range, the pH, pCO2, and bicarbonate (pHCO3) are all abnormal, indicating an ongoing imbalance.
B. Full compensation occurs when all components of the ABG are within or approaching normal range, indicating that the body's compensatory mechanisms have effectively counteracted the primary acid- base disturbance. In this option, the bicarbonate (pHCO3) is mentioned as starting to change, indicating incomplete compensation.
D. While the pH is within the normal range, both the pCO2 and pO2 are abnormal, indicating a primary respiratory disturbance. In the case of full compensation, the pH, pCO2, and bicarbonate (pHCO3) levels would all be within or approaching normal range, indicating that the compensatory mechanisms have effectively counteracted the primary acid-base disturbance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Infiltration occurs when the intravenous solution leaks into the surrounding tissue instead of flowing into the vein. This can cause discomfort, swelling, and potential tissue damage. Stopping the infusion immediately helps prevent further infiltration and minimizes the risk of complications such as tissue necrosis or damage.
B. While documenting the findings is important for the client's medical record, it is not the first action to take when suspecting infiltration. Immediate intervention to stop the infusion and assess the site for complications takes precedence over documentation.
C. Flushing the catheter with normal saline may be necessary after stopping the infusion to ensure patency and clear any remaining solution from the catheter. However, this step should follow the immediate cessation of the infusion to prevent further infiltration.
D. Removing the catheter may be necessary if significant infiltration has occurred or if there are signs of tissue damage. However, this should be done after stopping the infusion to prevent further infiltration and should be based on the assessment findings and healthcare provider's instructions.
Correct Answer is C
Explanation
C. Assisting the client in slowed breathing techniques is the most appropriate initial intervention for a client experiencing hyperventilation due to acute psychological stress. Slowed breathing techniques, such as pursed-lip breathing or diaphragmatic breathing, can help normalize respiratory rate and depth, thereby correcting the respiratory alkalosis. Encouraging the client to breathe slowly and deeply can help reduce the respiratory rate and restore a more balanced acid-base status.
A. Administering a sedative may not be the initial intervention for a client experiencing hyperventilation due to acute psychological stress. Sedatives can depress the respiratory drive further and may exacerbate respiratory alkalosis. Additionally, administering sedatives should be based on a comprehensive assessment and medical prescription, rather than as a first-line intervention for hyperventilation.
B. While hyperventilation can sometimes lead to symptoms resembling seizure activity (such as muscle twitching or numbness), assessing for seizure activity is not typically the initial intervention for respiratory alkalosis. In the context of acute psychological stress causing hyperventilation, addressing the hyperventilation itself is the priority.
D. While monitoring vital signs, including blood pressure, is important in assessing the client's overall condition, it is not the initial intervention specifically for addressing respiratory alkalosis due to hyperventilation. The priority in this situation is to address the hyperventilation itself through appropriate breathing techniques.
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