A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following:
- pH is 7.12 (normal range: 7.35-7.45)
- PaCO2 is 90 mm Hg (normal range: 35-45)
- HCO3- is 22 mEq/L (normal range: 22-26)
The nurse interprets the results as indicating which condition?
Metabolic alkalosis
Respiratory alkalosis
Respiratory acidosis
Metabolic acidosis
The Correct Answer is C
A. Metabolic alkalosis is characterized by a high pH and elevated bicarbonate levels, which is not present in these results.
B. Respiratory alkalosis would present with an increased pH and decreased PaCO2, which does not apply here.
C. The low pH (7.12) indicates acidemia, and the elevated PaCO2 (90 mm Hg) suggests hypoventilation and respiratory acidosis due to CO2 retention. The bicarbonate level is within normal limits, further supporting respiratory acidosis.
D. Metabolic acidosis would be indicated by a low pH and low bicarbonate levels; however, the bicarbonate is normal in this case, ruling out metabolic acidosis.
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Correct Answer is A
Explanation
A. Vitamin D deficiency is a modifiable risk factor because it can be addressed through dietary changes, supplements, and increased sun exposure.
B. A small-boned, thin frame is considered a nonmodifiable risk factor as it is a genetic characteristic that cannot be changed.
C. A personal history of fractures is also a nonmodifiable risk factor, as past fractures indicate an increased risk for future fractures and cannot be altered.
D. Age is a nonmodifiable risk factor, as it is an intrinsic characteristic that cannot be changed.
Correct Answer is B
Explanation
A. The planning phase involves setting goals and determining interventions based on the assessment data.
B. The assessment phase is where the nurse gathers information about the client's health history, including potential allergies, which is essential for safe care and diagnostic testing.
C. The implementation phase involves carrying out the planned interventions, which would include considerations for allergies but not the initial questioning about them.
D. The evaluation phase assesses the effectiveness of the interventions and the client's response to care, which is not the appropriate time to inquire about allergies.