The following arterial blood gas results would demonstrate to the nurse that the client is experiencing which acid-base imbalance? pH 7.31 PaCO2 40, HCO3 18, pa02 92

Respiratory alkalosis

Respiratory acidosis

Metabolic alkalosis

Metabolic acidosis

Answer and Explanation

The Correct Answer is D

D. In metabolic acidosis, the pH would be low (acidemic) and the HCO3 level would be below the normal range. In the provided ABG results, the pH is low (acidemic) and the HCO3 level is below the normal range, indicating metabolic acidosis.

A. In respiratory alkalosis, the pH would be elevated (alkalotic) and the PaCO2 would be below the normal range (hypocapnia). However, in the provided ABG results, the pH is low (acidemia) rather than high, ruling out respiratory alkalosis.
B. In respiratory acidosis, the pH would be low (acidemic) and the PaCO2 would be above the normal range (hypercapnia). However, in the provided ABG results, the PaCO2 is within the normal range, ruling out respiratory acidosis.
C. In metabolic alkalosis, the pH would be elevated (alkalotic) and the HCO3 level would be above the normal range. However, in the provided ABG results, the pH is low (acidemic) and the HCO3 level is below the normal range, ruling out metabolic alkalosis.

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Correct Answer is B

Explanation

B. Elevating the head of the bed to 30-45 degrees is the recommended position for administering enteral feeding to reduce the risk of aspiration. This semi-upright position helps promote gastric emptying and reduces the likelihood of reflux or regurgitation of the feed into the lungs. It also allows for better tolerance of the feeding and minimizes the risk of complications.
A. Positioning the client on the left side with the knees bent is not typically recommended for enteral feeding. This position may increase the risk of aspiration, especially if the client has impaired swallowing or if there are issues with gastric emptying. It may also not be the most comfortable or practical position for administering enteral feeding.
C. Positioning the client on the right side with a pillow behind the back is not a standard practice for administering enteral feeding. This position may not provide optimal access for administering the feed, and it does not offer the benefits of head elevation to reduce the risk of aspiration.

D. Elevating the head of the bed to only 15 degrees may not provide sufficient upright positioning to reduce the risk of aspiration during enteral feeding. While it is better than lying completely flat, a higher degree of elevation (30-45 degrees) is generally recommended for optimal safety and effectiveness of enteral feeding.

A. Encourage the client to try ways to stay awake during the day. B. Substitute physical therapy for one of the client's usual nap times. C. Ask the physician to order a sleeping pill for the client to take at night. D. Do nothing, as no action is necessary in this situation.

Correct Answer is D

Explanation

D. It is important to recognize and respect the client's natural sleep patterns, especially considering their age and current health status. Napping during the day can be a normal and beneficial behavior for older adults, helping to replenish energy levels and promote overall well-being. As long as the client's napping does not interfere with their ability to sleep at night or their daily activities, no intervention may be necessary.
A. Encouraging the client to stay awake during the day may not be appropriate, especially considering the client's age and natural sleep patterns. Older adults often experience changes in their sleep-wake cycle, including more frequent napping during the day.
B. Physical activity is important for maintaining mobility and overall health but substituting physical therapy for one of the client's usual nap times may not be feasible or beneficial. The client's need for rest and sleep should be respected, especially if they are experiencing fatigue or illness.
C. Prescribing a sleeping pill for the client may not be appropriate, especially if they are already napping during the day. Sleep medications can have side effects, including drowsiness, confusion, and increased risk of falls, particularly in older adults.

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The following arterial blood gas results would demonstrate to the nurse that the client is experiencing which acid-base imbalance? pH 7.31 PaCO2 40, HCO3 18, pa02 92

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is about to administer a bolus enteral feeding to a client who is on bedrest. How does the nurse position the client during the feeding?

Correct Answer is B

Explanation

The nurse is caring for a 96-year-old client who has been admitted for treatment of a urinary tract infection. The nurse notices that the client takes two one-hour naps each day, one mid-morning and the other late afternoon. What intervention should the nurse implement?

Correct Answer is D

Explanation

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