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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A rosebud like stoma orifice is a normal appearance for a new colostomy, indicating that the stoma is healthy and not in distress.
Choice B reason: Red drainage from a stoma can be normal, especially in the early postoperative period, as the stoma may ooze a small amount of blood. However, if the drainage is excessive or persistent, it should be reported.
Choice C reason: A shiny, moist stoma is also a sign of a healthy stoma. The stoma should be moist and have a pink or red color, similar to the inside of the mouth.
Choice D reason: A purplish colored stoma indicates compromised blood flow and is a sign of ischemia. This is a serious complication that requires immediate medical attention to prevent tissue death.
Correct Answer is C
Explanation
Choice A reason: The statement is incorrect because TSH does not attach to a protein in the blood; it stimulates the thyroid gland to produce thyroid hormones.
Choice B reason: This choice is partially correct. TSH does stimulate the thyroid gland, but the main purpose of the test is not to measure the 'feeding' of the gland but to assess its function and how well it's producing thyroid hormones.
Choice C reason: This is the correct statement. TSH levels are measured to determine the thyroid gland's activity, which directly influences the metabolic rate. The normal range for TSH levels in adults is typically 0.4 to 4.0 milliunits per liter (mU/L). However, these values can vary slightly based on the laboratory and the age of the individual.
Choice D reason: While TSH does influence energy levels by regulating thyroid hormone production, this choice does not directly explain the purpose of measuring TSH levels.
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