Adult Health lll Exam 1 Answers 1. The nurse should interpret the arterial blood gas results shown below as which of the following? pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L a. respiratory alkalosis b. metabolic acidosis c. metabolic alkalosis d. respiratory acidosis Feedback: The ABGs shown indicate the pH is high which would mean alkalosis. The PaCO2 is low which is the opposite of the pH and indicates that the respiratory system is the primary problem. The HCO3 is within normal levels. Remember the acronym ROME when interpreting ABGs.Lewis 2017, pgs 290-291abcK 2. The nurse is caring for a client who is receiving prescribed intravenous (IV) fluids at 50 ml/hr, has voided 300 ml in 24-hours and reports having a headache. The nurse notes the client's laboratory results show a low urine specific gravity level. Which of the following actions should the nurse take? a. Encourage the client to increase their fluid intake. b. Decrease the intravenous fluids. c. Administer prescribed antibiotics. d. Assist the client to ambulate to increase their metabolic rate. Feedback: Acute renal failure manifests as oliguria, anuria, or normal urine volume. Oliguria (less than 400 mL/d of urine) is the most common clinical situation seen in acute renal failure along with a low urine specific gravity; anuria (less than 50 mL/d of urine) and normal urine output are not as common. In acute renal failure you want to encourage the client to increase their fluid intake to prevent dehydration. Administering antibiotics will not increase the client's decreased urine output. Decreasing IV fluids will be putting the client at risk for dehydration. Increasing the metabolic rate will not assist the client in their urine output deficit. Lewis 2017, pgs. 1071-1072abkd 3. The plan of care for a client with a low potassium level includes providing information about the effects of medications and the dietary intake of foods high in potassium. Which of the following information should the nurse use to evaluate if the outcome for the plan was met? a. laboratory data b. physical assessment c. health history d. client statements Feedback: The interventions are aimed at increasing the potassium level of the client, and achievement would be measured by evaluating laboratory data. Potassium levels cannot be measured by physical assessment, health history information, or client statements. Lewis 2017, pgs. 282-283 4. The nurse caring for a client experiencing acute hypoxemic respiratory failure due to V/Q mismatch is evaluating the client’s plan of care. Which of the following interventions would be appropriate for the client’s care plan? a. Initiate 24% to 32% oxygen via face mask. b. Provide high flow supplemental oxygen via nasal cannula. c. Provide oxygen via noninvasive positive pressure ventilation (NIPPV). d. Initiate invasive positive pressure ventilation (PPV) via endotracheal tube for SaO2 below 90%.