L). [Normal HCO3 is 22-26]

The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis

Respiratory alkalosis

Metabolic acidosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is A

A. Respiratory acidosis: The pH is low (indicating acidosis), and the Paco₂ is elevated, which signifies that carbon dioxide retention is causing the acidosis. This pattern indicates respiratory acidosis, as the elevated HCO₃ suggests a compensatory response.

B. Respiratory alkalosis: Respiratory alkalosis would show a high pH with a low Paco₂. This is not consistent with the client’s lab results.

C. Metabolic acidosis: Metabolic acidosis would show a low pH with a low HCO₃. In this case, the HCO₃ is slightly elevated, ruling out metabolic acidosis.

D. Metabolic alkalosis: Metabolic alkalosis would show a high pH with an elevated HCO₃, which does not match the client’s results.

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A. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. B. The nurse will briefly touch the client, and the client will need to identify where the touch occurred. C. Client will close their eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. D. The client is to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time.

Correct Answer is C

Explanation

A. This description relates more to a sensory discrimination test, not graphesthesia.

B. This option does not accurately describe the graphesthesia test, which involves identifying shapes or numbers rather than just touch location.

C. In the graphesthesia test, the client closes their eyes while the nurse uses a blunt object to write a number or shape in the client's palm, and the client must identify what was written. This assesses the ability to recognize letters or numbers drawn on the skin.

D. This option describes a two-point discrimination test rather than graphesthesia, which focuses on identifying drawn shapes or numbers.

A. Metabolic alkalosis B. Respiratory alkalosis C. Respiratory acidosis D. Metabolic acidosis

Correct Answer is C

Explanation

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 C

Explanation

Correct Answer is C

Explanation

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A nurse is precepting a nursing student. The nurse explains to the nursing student how you would perform the graphesthesia test on a client. What is the correct way to perform this test?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

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