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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
A. Facial drooping is a common symptom following a stroke, particularly if it affects areas of the brain responsible for facial movement.
B. Frequent diarrhea is not typically associated with stroke and may be related to other factors.
C. A steady gait is unlikely following a stroke, especially if the stroke has affected motor control or balance.
D. Vocal clarity can be affected after a stroke, but facial drooping is a more immediate and recognizable alteration in neurologic function.
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.