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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A reason: Neurological checks are essential after spinal surgery to monitor for any changes or deterioration in the patient's neurological status. The frequency of these checks can vary based on the patient's condition, but a common standard is to perform them every 4 hours or sooner. However, in some cases, especially immediately post operation, checks may be required more frequently, such as every 2 hours, to ensure any complications are identified and managed promptly.

Choice B reason: While mobilization is an important aspect of postsurgical care to prevent complications such as deep vein thrombosis, positioning a patient in a chair every 2 hours may not be appropriate immediately following spinal surgery. The patient's mobility and pain level must be assessed, and activities should be gradually increased as tolerated.

Choice C reason: Inspecting the spinal dressing is important to identify signs of infection or complications. However, clear drainage is not typically expected and could indicate cerebrospinal fluid leakage, which requires immediate medical attention.

Choice D reason: The term "criminal checks" is not relevant to nursing care and seems to be a typographical error. The nurse's focus should be on clinical assessments and interventions related to the patient's health status.

A. Maple syrup B. Carrots C. Orange juice D. Raisins

Correct Answer is D

Explanation

Choice A reason: Maple syrup, while a source of energy, is not rich in iron or vitamins that can significantly contribute to increasing hemoglobin levels.

Choice B reason: Carrots are a good source of beta-carotene and fiber but are not particularly high in iron, which is necessary for increasing hemoglobin levels.

Choice C reason: Orange juice is rich in vitamin C, which can enhance iron absorption, but on its own, it does not contribute significantly to hemoglobin levels.

Choice D reason: Raisins are a good source of iron and can help increase hemoglobin levels. They are also convenient as a snack and can be easily incorporated into the diet.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has just had spinal surgery. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is creating a dietary plan for an adult female client who has a hemoglobin level of 9.8 g/dL. Which of the following foods should the nurse recommend?

Correct Answer is D

Explanation

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that his blood pressure of 124/79 mm Hg places him in which of the following categories?

A nurse caring for a client who has hypertension is asked about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions?

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point.

A nurse is educating coworkers on how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.)

A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching?

A client is about to undergo an abdominal paracentesis. In which of the following positions should the nurse place the client?

A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?