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 D
Explanation
A. In the anterior chest assessment, auscultation usually follows inspection and is typically done before percussion.
B. In the neck assessment, the nurse may inspect and then auscultate (e.g., carotid arteries) before palpation.
C. In the heart assessment, auscultation follows inspection but may not involve percussion.
D. In the abdomen, the correct order is to inspect, auscultate, and then percuss to assess bowel sounds effectively before creating additional disturbances with percussion.
Correct Answer is C
Explanation
A. Restlessness is an objective sign that may indicate pain, but it is not a subjective report from the client.
B. Pupil dilation is an objective physiological response often associated with pain or stress, not a subjective indicator.
C. A report of a burning sensation is a subjective indicator because it is based on the client’s own description of their pain experience.
D. Grimacing is an objective observation by the nurse, not a subjective report from the client.