Foundations of Care HESI Questions

The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication? Select all that apply. 1.) Timing 2.) Volume 3.) Voice tone 4.) Eye contact 5.) Hand gestures 6.) Ability to share thoughts and feelings

Answer(s): 1, 2, 3, 6 Rationale: Verbal communication includes not only one's language or dialect but also voice tone, volume, timing, and ability to share thoughts and feelings. It does not include eye contact or hand gestures.

The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions should the nurse include in performing this procedure? Select all that apply. 1.) Explaining the procedure to the client 2.) Clamping the tubing of the drainage bag 3.) Obtaining the specimen from the urinary drainage bag 4.) Aspirating a sample from the port on the drainage tubing 5.) Wiping the port with an alcohol swab before inserting the syringe

Answer(s): 1, 2, 4, 5 Rationale: A urine specimen is not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag, so its properties do not necessarily reflect current client status. In addition, it may become contaminated with bacteria from opening the system. The remaining options are correct interventions for obtaining the specimen.

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. 1.) Nausea 2.) Confusion 3.) Bradypnea 4.) Tachycardia 5.) Hyperkalemia 6.) Lightheadedness

Answer(s): 1, 2, 4, 6 Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.

The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse plans care knowing that what other extrapulmonary causes can lead to respiratory failure? Select all that apply. 1.) Stroke 2.) Pneumonia 3.) Sleep apnea 4.) Myasthenia gravis 5.) Obstructive lung disease 6.) Opioid analgesics, sedatives, anesthetics

Answer(s): 1, 3, 4, 6 Rationale: Extrapulmonary causes of respiratory failure include the following: stroke; sleep apnea; myasthenia gravis; and opioid analgesics, sedatives, and anesthetics. Both obstructive lung disease and pneumonia are intrapulmonary causes of respiratory failure.

The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply. 1.) Tetany 2.) Lethargy 3.) Tingling 4.) Confusion 5.) Numbness 6.) Restlessness

Answer(s): 1, 3, 5, 6 Rationale: A client's reaction to alkalosis causes tingling and numbness of the fingers, restlessness, and tetany caused by irritability of the central nervous system (CNS). If the severity of alkalosis increases, convulsions and coma may occur.

The nurse provides information to a client scheduled for a dual x-ray absorptiometry (DEXA) test. Which information should the nurse provide to the client? Select all that apply. 1.) It is a painless test. 2.) It emits slightly more radiation than a chest x-ray does. 3.) Upper body clothing will need to be removed for testing. 4.) Increased fluid intake is necessary following the procedure. 5.) Metallic objects such as jewelry or belt buckles may interfere with the test and need to be removed.

Answer(s): 1, 5 Rationale: The most commonly used screening and diagnostic tool for measuring bone mineral density is the dual x-ray absorptiometry (DEXA) test. It is a painless test that emits less radiation than a chest x-ray. A height is taken before the start of the test. The client stays dressed but is asked to remove any metallic objects such as belt buckles, coins, keys, or jewelry because they may interfere with testing. No special follow-up care for the test is necessary.

The nurse is caring for a client with metabolic alkalosis. The nurse plans care knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply. 1.) Buffer 2.) Cardiac 3.) Nervous 4.) Chemical 5.) Respiratory 6.) Neuromuscular

Answer(s): 2, 3, 6 Rationale: Most problems of alkalosis are related to increased stimulation of the cardiac, nervous, and neuromuscular systems. Chemical reactions are also called buffer systems and are not related to most problems of alkalosis. The respiratory system is related to respiratory alkalosis and not metabolic alkalosis.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1.) pH 7.25, Paco2 50 mm Hg (50 mm Hg) 2.) pH 7.35, Paco2 40 mm Hg (40 mm Hg) 3.) pH 7.50, Paco2 52 mm Hg (52 mm Hg) 4.) pH 7.52, Paco2 28 mm Hg (28 mm Hg)

Answer: 1 Rationale: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg (35 to 45 mm Hg). In respiratory acidosis, the pH is decreased and the Paco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.

The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions knowing that as the client's CO2 level rises, what will occur with the blood pH? 1.) Fall 2.) Rise 3.) Double 4.) Remain unchanged

Answer: 1 Rationale: CO2 acts as an acid in the body. A rise in blood CO2 will result in a fall in pH. The other options are incorrect.

A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base imbalance? 1.) Hypokalemia 2.) Hypercalcemia 3.) Hypochloremia 4.) Hypernatremia

Answer: 1 Rationale: Clinical manifestations of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. The clinical picture does not include hypercalcemia, hypochloremia, or hypernatremia.

A clinic nurse is performing an admission assessment on an African American client scheduled for cataract removal with intraocular lens implantation. Which question should the nurse avoid asking on the initial assessment? 1.) "Do you have any family problems?" 2.) "Do you ever experience chest pain?" 3.) "Do you have any problems urinating?" 4.) "Do you frequently have episodes of constipation?"

Answer: 1 Rationale: In the African American culture, it is considered to be intrusive to ask personal questions on the initial contact or meeting. African Americans are highly verbal and express feelings openly to family or friends, but what transpires within the family is viewed as private. The psychosocial assessment would be of lowest priority during the initial admission assessment. Additionally, because cardiovascular, renal, and gastrointestinal assessments are physiological, they are the priority assessments.

A client has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action? 1.) Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. 2.) Change the nasal cannula to a shovel face mask; then have the ABG samples drawn. 3.) Leave the nasal cannula in place and have the ABG samples drawn. 4.) Change the nasal cannula to a Venturi face mask; then have the ABG samples drawn.

Answer: 1 Rationale: The client should have oxygen supplementation removed for at least 15 minutes before ABGs are drawn if the client has a prescription for the ABGs to be drawn on room air. This allows time for the client's system to equilibrate so that the ABG results will accurately reflect ventilatory status without the supplemental oxygen. This prescription may be given when the primary health care provider is trying to decide whether to discontinue oxygen therapy, and it allows staff to observe how the client tolerates oxygen removal. Therefore, the remaining options are incorrect.

The prenatal clinic nurse is performing an assessment on a culturally diverse client. Besides conversational style, what are some of the most important cultural and communication considerations the nurse must be aware of? Select all that apply. 1.) Touch 2.) Eye contact 3.) Personal space 4.) Family presence 5.) Time orientation 6.) Facial expression

Answer: 1, 2, 3, 5 Rationale: The most important cultural and communication considerations the nurse must be aware of are touch, eye contact, personal space, and time orientation. Family presence and facial expression are not important concepts.

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client? 1.) Wearing gloves 2.) Wearing a gown and gloves 3.) Wearing a gown, gloves, and a mask 4.) Wearing a gown and gloves to change the bed linens, and gloves only for the bath

Answer: 2 Rationale: Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage, or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.

The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance? 1.) Metabolic acidosis 2.) Metabolic alkalosis 3.) Respiratory acidosis 4.) Respiratory alkalosis

Answer: 2 Rationale: Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. The remaining acid-base disturbances are incorrect.

The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value should the nurse expect to note? 1.) Sodium level of 145 mEq/L (145 mmol/L) 2.) Potassium level of 5.2 mEq/L (5.2 mmol/L) 3.) Phosphorus level of 3.0 mg/dL (0.97 mmol/L) 4.) Magnesium level of 1.3 mg/dL (0.53 mmol/L)

Answer: 2 Rationale: Interpretation of the arterial blood gas (ABG) indicates metabolic acidosis with partial compensation by the respiratory system. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul's respirations; headache; nausea, vomiting, and diarrhea; fruity-smelling breath resulting from improper fat metabolism; central nervous system depression, including mental dullness, drowsiness, stupor, and coma; twitching; and convulsions. Hyperkalemia will occur.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? 1.) Metabolic acidosis 2.) Metabolic alkalosis 3.) Respiratory acidosis 4.) Respiratory alkalosis

Answer: 2 Rationale: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1.) Sodium level of 145 mEq/L (145 mmol/L) 2.) Potassium level of 3.0 mEq/L (3.0 mmol/L) 3.) Magnesium level of 1.3 mEq/L (0.65 mmol/L) 4.) Phosphorus level of 3.0 mg/dL (0.97 mmol/L)

Answer: 2 Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client's safety by carefully implementing which prescribed precaution? 1.) Contact isolation 2.) Seizure precautions 3.) Bleeding precautions 4.) Neutropenic precautions

Answer: 2 Rationale: The client with metabolic alkalosis is at risk for tetany and seizures. The nurse would maintain client safety by using seizure precautions with this client. The remaining options are unnecessary in the care of the client experiencing metabolic alkalosis.

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client? 1.) Five blood cultures are negative. 2.) Three sputum cultures are negative. 3.) A blood culture and a chest x-ray are negative. 4.) A sputum culture and a tuberculin skin test are negative.

Answer: 2 Rationale: The client with tuberculosis must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative, because the client is considered noninfectious at that point. Options 1, 3, and 4 are not reliable determinants of a noninfectious status.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? 1.) Metabolic acidosis, compensated 2.) Respiratory alkalosis, compensated 3.) Metabolic alkalosis, uncompensated 4.) Respiratory acidosis, uncompensated

Answer: 2 Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value, and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

The nurse is caring for a client with diabetic ketoacidosis whose respirations are abnormally deep, regular, and increased in rate. What is the purpose of this type of respiration? Select all that apply. 1.) Correct bradypnea 2.) Blow off carbon dioxide 3.) Correct metabolic acidosis 4.) Correct an acid-base imbalance 5.) Cause respiratory compensation 6.) Stimulate Cheyne-Stokes respirations

Answer: 2, 3, 4, 5 Rationale: Abnormally deep, regular, and increased in rate respirations enable respiratory compensation in an effort to help correct metabolic acidosis. These respirations are called Kussmaul's respirations, and they occur by exhaling excess carbon dioxide. Bradypnea is abnormally slow but regular respirations. Cheyne-Stokes respirations have rhythmic crescendo and decrescendo of rate and depth, including brief periods of apnea. Kussmaul's respirations do not stimulate Cheyne-Stokes respirations.

A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply. 1.) Seizures 2.) Lethargy 3.) Headache 4.) Weakness 5.) Confusion 6.) Hyperactivity

Answer: 2, 3, 4, 5 Rationale: In both respiratory and metabolic acidosis, the central nervous system (CNS) is depressed. Headache, lethargy, weakness, and confusion develop, leading eventually to coma and death. Therefore, seizures and hyperactivity would not be noted.

Following myelography, how should the nurse plan to best position the client? 1.) On the left side 2.) On the right side 3.) Head slightly elevated 4.) Head lower than the rest of the body

Answer: 3 Rationale: A myelogram uses x-rays and contrast material to view the bones and the fluid-filled space (subarachnoid space) between the bones in the spine. It may be done to diagnose the presence of a tumor, an infection, problems with the spine such as a herniated disc, or narrowing of the spinal canal caused by arthritis. The head should be slightly elevated to prevent complications such as leaking of cerebrospinal fluid.

The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse is demonstrating correct procedure when which technique is performed? 1.) Ask the client to void, save the specimen, and note the start time. 2.) Place the specimen in various containers as necessary for the test. 3.) Ask the client to save a sample voided at the end of the collection time. 4.) Remove urine from the collection container for other prescribed specimens.

Answer: 3 Rationale: Because the 24-hour urine test is a timed quantitative determination, the test must be started with an empty bladder; therefore, the first urine is discarded. Fifteen minutes before the end of the collection time, the client should be asked to void, and this specimen is added to the collection. The urine sample should be placed in the appropriate container and may be refrigerated or placed on ice to prevent changes in the urine. Because this is a quantitative determination of constituents in the urine, no urine should be removed from the container.

Which is the best nursing intervention regarding complementary and alternative medicine? 1.) Advising the client about "good" versus "bad" therapies 2.) Discouraging the client from using any alternative therapies 3.) Educating the client about therapies that he or she is using or is interested in using 4.) Identifying herbal remedies that the client should request from the primary health care provider

Answer: 3 Rationale: Complementary and alternative therapies include a wide variety of treatment modalities that are used in addition to conventional therapy to treat a disease or illness. Educating the client about therapies that he or she uses or is interested in using is the nurse's role. Options 1, 2, and 4 are inappropriate actions for the nurse to take because they provide advice to the client.

The nurse is annoyed by a healthy Hispanic American client who had minor abdominal surgery 2 days ago. The client claims he cannot get out of bed by himself, and the nurse lectures the client and tells him to try to be tough. What type of cultural behavior is this called? 1.) Cultural ignorance 2.) Cultural blindness 3.) Cultural imposition 4.) Cultural transmission

Answer: 3 Rationale: Nurses and other primary health care providers who have cultural ignorance or cultural blindness about differences generally resort to cultural imposition. They use their own values and lifestyles as the absolute guide in dealing with clients and interpreting their behaviors.

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance? 1.) Metabolic acidosis 2.) Metabolic alkalosis 3.) Respiratory acidosis 4.) Respiratory alkalosis

Answer: 3 Rationale: The normal pH is 7.35 to 7.45. Normal PaCO2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and PaCO2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1.) Bradycardia and hyperactivity 2.) Decreased respiratory rate and depth 3.) Headache, restlessness, and confusion 4.) Bradypnea, dizziness, and paresthesias

Answer: 3 Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? 1.) Side-lying with a pillow under the hip 2.) Prone with a pillow under the abdomen 3.) Prone in slight Trendelenburg's position 4.) Side-lying with the legs pulled up and the head bent down onto the chest

Answer: 4 Rationale: A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the primary health care provider. The nurse remains with the client during the procedure to help the client maintain this position. The other options identify incorrect positions for this procedure.

The nurse is preparing to care for a client following a gastroscopy procedure. Which priority component should the nurse include in the nursing care plan? 1.) Monitor the client's vital signs every hour for 4 hours. 2.) Place the client in a supine position to provide comfort. 3.) Provide saline gargles immediately on return to the unit to aid in comfort. 4.) Check the gag reflex by using a tongue depressor to stroke the back of the client's throat.

Answer: 4 Rationale: Before the gastroscopy procedure, medication is given to prevent a gag reflex. On return from the procedure, the nurse must test the client's gag reflex to ensure that it is present to prevent aspiration of contents. Vital signs should be taken every 30 minutes for 2 hours to detect abnormalities. The client must be placed in a side-lying or semi-Fowler's position to avoid aspiration. Saline gargles must be administered only when the gag reflex has been confirmed.

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1.) A decreased pH and an increased Paco2 2.) An increased pH and a decreased Paco2 3.) A decreased pH and a decreased HCO3- 4.) An increased pH and an increased HCO3-

Answer: 4 Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1.) Headache and tachypnea 2.) Hyperactivity and dyspnea 3.) Muscle twitches and cyanosis 4.) Lightheadedness and paresthesias

Answer: 4 Rationale: Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. The remaining three options are not clinical manifestations of respiratory alkalosis.

A client is to undergo pleural biopsy at the bedside. When planning for any potential complications of the procedure, the nurse should have which item(s) available at the bedside? 1.) Intubation tray 2.) Morphine sulfate injection 3.) Portable chest x-ray machine 4.) Chest tube and drainage system

Answer: 4 Rationale: Complications following pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse should have a chest tube and drainage system available at the bedside for use if hemothorax or pneumothorax develops. An intubation tray is not indicated. The client may be premedicated before the procedure, or a local anesthetic is used. A portable chest x-ray machine would be needed to verify placement of a chest tube if one was inserted, but it is unnecessary to have at the bedside before the procedure.

The nurse is implementing the complementary therapy of therapeutic touch when caring for clients. The nurse should implement which action when performing therapeutic touch? 1.) Apply heating pads to the back. 2.) Vigorously massage bony prominences. 3.) Position hands directly on the client's skin. 4.) Position hands 2 to 4 in (5 to 10 cm) from the body

Answer: 4 Rationale: During therapeutic touch, nurses use their hands to assess the client's energy field. Hands are positioned 2 to 4 in (5 to 10 cm) from the body. The energy field is assessed for bilateral similarities or differences in the flow of energy. The next step is clearing and balancing the energy field. Nurses then redirect energy through their own intentionality. The session ends with a smoothing of the energy. Therefore, the remaining options are incorrect.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mm Hg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? 1.) The client has acidotic blood. 2.) The client is probably overreacting. 3.) The client is fluid volume overloaded. 4.) The client is probably hyperventilating.

Answer: 4 Rationale: The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an insufficient analysis. No conclusion can be made about a client's fluid volume status from the information provided.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? 1.) Metabolic acidosis with compensation 2.) Respiratory acidosis with compensation 3.) Metabolic acidosis without compensation 4.) Respiratory acidosis without compensation

Answer: 4 Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm). In respiratory acidosis, the pH is decreased and the Pco2 is elevated. The normal bicarbonate (HCO3-) level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur? 1.) The client will lose consciousness. 2.) The client's sodium and chloride levels will rise. 3.) The client will complain of facial numbness and tingling. 4.) The client's arterial blood gas results will reflect acidosis.

Answer: 4 Rationale: When the client with respiratory disease retains CO2, a rise in CO2 will occur. This results in a corresponding fall in pH, thus respiratory acidosis. This concept forms the basis for key aspects of acid-base balance. The other options are incorrect and are not associated with this initial physical response.