The nurse reviews the arterial blood gas results of an assigned client and notes the laboratory report results
pH of 7.30, [normal pH is 7.35 to 7.45]
Paco2 of 58 mm Hg, [Normal Paco2 is 35 to 45 mm Hg]
Pao2 of 80 mm Hg. [normal is 80-100]
HCO3 of 27 mEq/L (27 mmol/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
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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Correct Answer is B
Explanation
A. The palm is not the best part of the hand to assess lymph nodes, as it lacks the sensitivity needed for palpation.
B. The parts of the fingers, particularly the pads of the fingers, are used to assess lymph node size. This allows for a more precise and sensitive examination of the lymph nodes.
C. The dorsal side of the hand is not typically used for palpation because it is less sensitive.
D. The ulnar surface of the hand is not commonly used for this purpose, as the fingertips provide better tactile sensation for assessing lymph node size.
Correct Answer is ["A","B"]
Explanation
A. Bronchovesicular sounds are normal lung sounds that are typically heard over the mainstem bronchi and are expected during auscultation.
B. Bronchial sounds are also normal and are typically heard over the trachea; they are expected lung sounds.
C. Dullness is not a lung sound but rather a descriptor of percussion notes, typically indicating fluid or solid mass in the lungs.
D. Flatness is also not a normal lung sound but refers to a percussion note that can suggest the presence of fluid or a solid mass.