Mrs. Jamerson, who is in the post anesthesia care unit (PACU) following surgery, is difficult to arouse and demonstrates shallow breathing. The patient does not respond to any stimuli. The nurse assesses the patient and obtains arterial blood gas (ABG) measurements STAT. The ABG shows a pH of 7.10, PaCO2 of 70 mm Hg, and HCO3 of 24 mEq/L. What does this mean?

Respiratory Alkalosis Partially Compensated

Respiratory Acidosis Uncompensated

Metabolic Alkalosis Partially Compensated

Metabolic Acidosis Uncompensated

Answer and Explanation

The Correct Answer is B

Choice A reason: Respiratory Alkalosis Partially Compensated is characterized by an elevated pH over 7.45 and a PaCO2 under 35 mmHg, with a compensatory acidic HCO3 under 22 mEq/L. This does not match the patient's ABG results.

Choice B reason: Respiratory Acidosis Uncompensated is indicated by an acidic pH under 7.35 and an elevated PaCO2 over 45 mmHg, with HCO3 in the normal range of 2226 mEq/L. The patient's ABG results show a low pH and high PaCO2, which aligns with this condition.

Choice C reason: Metabolic Alkalosis Partially Compensated would show a basic pH over 7.45 and a basic HCO3 over 26 mEq/L, with a compensatory acidic PaCO2 over 45 mmHg[^10^]. The patient's ABG values do not support this diagnosis.

Choice D reason: Metabolic Acidosis Uncompensated would present with an acidic pH under 7.35 and an acidic HCO3 under 22 mEq/L, with PaCO2 in the normal range of 3545 mmHg⁸. The patient's normal HCO3 level does not indicate metabolic acidosis.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: This is incorrect. While gentle hair care is important, it is not as critical as sun protection for SLE patients.

Choice B reason: This is incorrect. Powder can be drying, and SLE patients often need to keep their skin moisturized.

Choice C reason: This is correct. SLE patients are often photosensitive and need to protect their skin from UV rays.

Choice D reason: This is incorrect. SLE patients should keep their skin well moisturized to prevent dryness.

A. Keep the client NPO B. Observe the client carefully for signs of hypocalcemia C. Provide a quiet, low stimulus environment D. Administer aspirin as prescribed for any sign of hyperthermia

Correct Answer is C

Explanation

Choice A reason: Keeping the client NPO (nothing by mouth) is not directly related to preventing a thyroid crisis. While it may be necessary in some situations, such as preoperative care, it does not address the hyperthyroid state.

Choice B reason: Observing the client for signs of hypocalcemia is important, especially after thyroid surgery, as hypocalcemia can occur due to accidental removal or damage to the parathyroid glands. However, it is not a preventive measure for a thyroid crisis.

Choice C reason: Providing a quiet, low stimulus environment can help reduce stress and agitation, which are potential triggers for a thyroid crisis. Stress can exacerbate hyperthyroid symptoms and precipitate a crisis.

Choice D reason: Aspirin is contraindicated in clients with hyperthyroidism as it can increase thyroid hormone levels by displacing them from their binding proteins. This can potentially worsen the condition and lead to a crisis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

A nurse is caring for a client who recently had surgery for the insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

A nurse is assessing a client who has chronic bronchitis. Which of the following percussion sounds should the nurse expect?

A nurse is evaluating the laboratory report for a client who has severe diarrhea and a fever. Which of the following laboratory findings should the nurse identify as an indication that the client has a parasitic infection rather than a bacterial infection?

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barre syndrome (GBS). Which of the following questions should the nurse ask the client?

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse an understanding of the procedure?

A nurse is talking with a young adult client who has a family history of osteoporosis. Which health promotion activity should the nurse recommend as a possible preventive measure?