Nursing 120 exam 3 Flashcards
) A client is brought to the emergency department (ED) after passing out in a local department store. The client has been fasting and has ketones in the urine. Which acid-base imbalance would the nurse expect to assess in this client? A) Metabolic acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Respiratory acidosis
Answer: A
Explanation: A) A client who is fasting is at risk for development of metabolic acidosis. The body recognizes fasting as starvation and begins to metabolize its own fatty acids into ketones, which are metabolic acids. Starvation would not result in respiratory acidosis or alkalosis or in metabolic alkalosis.
Which risk factors exhibited by the client presenting in the emergency department (ED) would place the client at risk for metabolic acidosis? Select all that apply. A) Abdominal fistulas B) Chronic obstructive pulmonary disease C) Pneumonia D) Acute renal failure E) Hypovolemic shock
Answer: A, D, E
Explanation: A) Metabolic acidosis is rarely a primary disorder. It usually develops during the course of another disease; presence of abdominal fistulas, which can cause excess bicarbonate loss; acute renal failure; and hypovolemic shock. Chronic obstructive pulmonary disease and pneumonia place the client at risk for respiratory acidosis with the increased retention of carbon dioxide in the blood.
A child with acute asthma has a PaCO2 of 48 mmHg, a pH of 7.31, and a normal HCO3 blood gas value. The nurse interprets these findings as indicative of which condition? A) Metabolic acidosis B) Respiratory alkalosis C) Respiratory acidosis D) Metabolic alkalosis
Answer: C
Explanation: A) If the pH is decreased and the PaCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis. Uncompensated respiratory alkalosis has an increased pH, decreased PaCO2, and normal HCO3. Uncompensated metabolic acidosis has a decreased pH, normal PaCO2, and decreased HCO3. Uncompensated metabolic alkalosis has an increased pH, normal PaCO2, and increased HCO3.
) The nurse is reviewing the latest arterial blood gas results for a client with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated? A) pH 7.32 B) PaCO2 18 mmHg C) HCO3 8 mEq/L D) PaCO2 48 mmHg
) The nurse is reviewing the latest arterial blood gas results for a client with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated?
A) pH 7.32
B) PaCO2 18 mmHg
C) HCO3 8 mEq/L
D) PaCO2 48 mmHg
Answer: D
Explanation: A) A normal pH level is 7.35-7.45. A pH of less than 7.35 is acidosis. A PaCO2 level of 18 mmHg is low and is seen in respiratory alkalosis. A HCO3 level of 8 mEq/L is low and is most likely associated with metabolic acidosis. In metabolic alkalosis, there is an excess of bicarbonate. To compensate for this imbalance, the rate and depth of respirations decrease, leading to retention of carbon dioxide. The PaCO2 will be elevated.
A client has been admitted with chronic obstructive pulmonary disease. Diagnostic tests have been ordered. Which of the tests will provide the most accurate indicator of the client's acid-base balance? A) Arterial blood gases (ABGs) B) Pulse oximetry C) Sputum studies D) Bronchoscopy
Answer: A
Explanation: A) ABGs are done to assess alterations in acid-base balance caused by respiratory disorders, metabolic disorders, or both. A bronchoscopy provides visualization of internal respiratory structures. Sputum studies can provide specific information about bacterial organisms. Pulse oximetry is a noninvasive test that evaluates the oxygen saturation level of blood.
The nurse is instructing a client with a history of acidosis on the use of sodium bicarbonate. Which client statement indicates that additional teaching is needed?
A) “I should contact the doctor if I have any gastric discomfort with chest pain.”
B) “I need to purchase antacids without salt.”
C) “I should use the antacid for at least 2 months.”
D) “I should call the doctor if I get short of breath or start to sweat with this medication.”
Explanation: A) The client should be instructed to immediately contact the primary healthcare provider if gastric discomfort occurs with chest pain or if dyspnea or diaphoresis occurs. The client should be instructed to use non-sodium antacids to prevent the absorption of excess sodium or bicarbonate into systemic circulation and to not use any bicarbonate antacid for longer than 2 weeks.
The client is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to diabetic coma. The nurse assesses the client to be lethargic, confused, and breathing rapidly. Which is the nurse’s priority response to the current situation?
A) Stop the infusion and notify the physician because the client is in alkalosis.
B) Decrease the rate of the infusion and continue to assess the client for symptoms of alkalosis.
C) Continue the infusion, because the client is still in acidosis, and notify the healthcare provider.
D) Increase the rate of the infusion and continue to assess the client for symptoms of ac
Answer: C
Explanation: A) The client receiving sodium bicarbonate is prone to alkalosis; monitor for cyanosis, slow respirations, and irregular pulse. The client’s symptoms do not indicate alkalosis so infusion should not be stopped. The client continues to exhibit signs of acidosis; symptoms of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid respiration rate that indicates an attempt by the lungs to rid the body of excess acid, and the physician should be notified. The infusion should not be increased or decreased without a practitioner order.
The nurse is preparing to analyze a client’s arterial blood gas results. List the steps in the order that the nurse should follow when analyzing this laboratory test.
- Look at the PaCO2.
- Look at the pH.
- Evaluate the relationship between pH and PaCO2.
- Look for compensation.
- Evaluate the pH, HCO3, and base excess for a possible metabolic problem.
- Look at the bicarbonate.
- Evaluate oxygenation
Answer: 2, 1, 3, 6, 5, 4, 7
Explanation:
1. The second step is to look at the PaCO2. If the PaCO2 is <35, then more carbon dioxide is being exhaled. If the PaCO2 is >45, then more carbon dioxide is being retained.
2. The pH is the first step and is analyzed to determine if acidosis or alkalosis is present. A pH of <7.35 is acidosis. A pH of >7.45 is alkalosis.
3. The third step is to evaluate the relationship between the pH and the PaCO2. This relationship could indicate a respiratory problem. If the pH is acidotic and the carbon dioxide level is greater than 45, then the client could be experiencing respiratory acidosis. If the pH is alkalotic and the carbon dioxide level is below 35, then the client could be experiencing respiratory alkalosis.
4. The sixth step is to look for compensation. Two things can occur in renal compensation. In respiratory acidosis, the kidneys retain HCO3 to buffer the excess acid, so the HCO3 is >26 mEq/L. In respiratory alkalosis, the kidneys excrete HCO3 to minimize the alkalosis, so the HCO3 is <22 mEq/L. Two things can also occur in respiratory compensation. In metabolic acidosis, the rate and depth of respirations increase, increasing carbon dioxide elimination, so the PaCO2 is <35 mmHg. In metabolic alkalosis, respirations slow and carbon dioxide is retained, so the PaCO2 is >45 mmHg.
5. The fifth step is to evaluate the pH, HCO3, and base excess for a possible metabolic problem. If the pH is <7.35, the HCO3 is <22 mEq/L, and the BE is less than −3 mEq/L, then low bicarbonate levels and high H+ concentrations are causing metabolic acidosis. If the pH is >7.45, the HCO3 is >26 mEq/L, and the BE is greater than +3 mEq/L, then high bicarbonate levels are causing metabolic alkalosis.
6. The fourth step is to look at the bicarbonate level. If the bicarbonate level is <22, then the levels are lower than normal. If the bicarbonate level is > 26, then the bicarbonate levels are higher than normal.
7. The final step is to evaluate oxygenation. If the PaO2 is <80 mmHg, then the client is experiencing hypoxemia and possible hypoventilation. If the PaO2 is >100 mmHg, then the client is hyperventilating.
9) The nurse is identifying a diagram to use to explain a client’s acid-base balance. Which imbalance does the following diagram suggest is occurring with the client?
The nurse is caring for a comatose client with metabolic acidosis. For which intervention will the nurse need to collaborate when caring for this client?
A) Measuring vital signs
B) Measuring intake and output
C) The client’s recent eating behaviors
D) Identifying current oxygen saturation level
Answer: C
Explanation: A) For clients in severe distress, family members may need to be consulted for critical information such as recent eating habits and history of vomiting. Measuring vital signs, measuring intake and output, and identifying current oxygen saturation level are independent nursing actions.
Answer: C
Explanation: A) For clients in severe distress, family members may need to be consulted for critical information such as recent eating habits and history of vomiting. Measuring vital signs, measuring intake and output, and identifying current oxygen saturation level are independent nursing actions.
Answer: B
Explanation: A) The pH measures the concentration of hydrogen ions (H+) in the body. Sodium (Na+) and chloride (Cl-) concentrations are not related to pH. Bicarbonate (HCO3) is a weak base that is used as a buffer to help maintain the proper pH, but it is not used to measure pH.
A client with a suspected acid-base imbalance has arterial blood gases tested. The test reveals a serum bicarbonate level of 22 mEq/L. The nurse understands that this bicarbonate level is A) slightly high. B) slightly low. C) extremely high. D) within normal range.
Answer: B
Explanation: A) The normal serum bicarbonate level is 24-28 mEq/L. Therefore, the nurse would understand that the client’s bicarbonate level is slightly low.
If a change in acid-base balance is due to hypoventilation or hyperventilation, the nurse will need to primarily focus on which concept related to acid-base balance? A) Oxygenation B) Perfusion C) Cognition D) Stress and coping
Answer: A
Explanation: A) Hypoventilation and hyperventilation are related to oxygenation. Respiratory rate helps regulate carbon dioxide pressures, which can contribute to acidosis or alkalosis. The nurse can help reverse respiratory acidosis or alkalosis by helping the client control their respiratory rate to restore normal oxygenation. Perfusion, cognition, and stress and coping do not directly relate to hypo- or hyperventilation.
When considering acid-base balance, health promotion should focus on A) conducting yearly health screenings. B) obtaining immunizations. C) beginning an exercise regimen. D) maintaining fluid balance.
Answer: D
Explanation: A) Both overhydration and dehydration can result in acid-base imbalances. Therefore, health promotion should focus on maintaining fluid balance. Beginning an exercise regimen, obtaining immunizations, and conducting yearly health screenings are activities that can promote health in other areas.
The nurse performing a blood draw for arterial blood gases first performs a modified Allen test for what purpose?
A) To reduce the risk of bleeding or bruising of the arm
B) To determine if arterial puncture can safely be performed
C) To determine the oxygen saturation of the blood in the artery
D) To determine the pressure of the blood in the artery
Answer: B
Explanation: A) A modified Allen test is a measure of ulnar patency. The patient elevates the hand and repeatedly makes a fist while the examiner places digital occlusive pressure over the radial and ulnar arteries of the wrist. The hand will lose its normal color. Digital pressure is released from one artery while the other remains compressed. The return of color indicates that the hand has good collateral supply of blood and that arterial puncture can safety be performed. The modified Allen test does not measure oxygen saturation or artery pressure, and it does not reduce the risk of bleeding or bruising.
) An intervention that can be implemented independently by the nurse caring for a client with an acid-base balance is
A) monitoring intake and output.
B) drawing blood for ABGs.
C) giving sodium bicarbonate infusions.
D) administering oxygen via nasal cannula.
Answer: A
Explanation: A) Monitoring intake and output is an independent nursing intervention that does not require a provider’s orders. Drawing blood for ABGs, giving sodium bicarbonate infusions, and administering oxygen via nasal cannula are all actions that can be performed by the nurse, but they must first be ordered by a provider.
Why should a nurse take daily weights of a client with acid-base balance? A) It helps monitor oxygenation status. B) It helps monitor perfusion of organs. C) It helps monitor renal function. D) It helps monitor fluid balance.
Answer: D
Explanation: A) Fluid balance must be maintained to support acid-base balance. If a client rapidly gains weight, it is a sign of fluid overload. If a client rapidly loses weight, it is a sign of dehydration. Both of these conditions can alter the acid-base balance, so a client’s weight should be monitored daily. A client’s weight does not reflect oxygenation status or perfusion of organs. Daily weights can reflect renal function, but weight can fluctuate even if the kidneys are functioning properly.
The nurse is analyzing the client's arterial blood gas report, which reveals a pH of 6.58. The client has just suffered a cardiac arrest. Which consequences of this pH value does the nurse consider for this client? A) Decreased cardiac output B) Increase magnesium levels C) Decreased free calcium in the ECT D) Increased myocardial contractility
Answer: A
Explanation: A) The nurse knows that severe acidosis (pH of 7.0 or less) depresses myocardial contractility, which leads to decreased cardiac output. Acid-base imbalances also affect electrolyte balance. In acidosis, calcium is released from its bonds with plasma proteins, increasing the amount of ionized (free) calcium in the blood. Magnesium levels may fall in acidosis.
The nurse is caring for a client who has been admitted with persistent diarrhea lasting 3 days. Which are appropriate nursing diagnoses for this client during the acute phase of the illness? Select all that apply. A) Decreased Cardiac Output B) Ineffective Airway Clearance C) Overflow Urinary Incontinence D) Knowledge Deficit E) Risk for Injury
Answer: A, E
Explanation: A) Metabolic acidosis decreases cardiac output by decreasing contractility, slowing the heart rate, and increasing the risk for dysrhythmias. The client with metabolic acidosis is also at risk for injury due to altered mental status. Appropriate nursing diagnoses during the acute phase of illness are Risk for Injury and Decreased Cardiac Output. The client may have a knowledge deficit, but this is not an appropriate nursing diagnosis during the acute phase of the illness. The client with metabolic acidosis is not at risk for Ineffective Airway Clearance or Overflow Urinary Incontinence.
The nurse is caring for a client with metabolic acidosis. Which goals are appropriate for this client? Select all that apply.
A) The client will maintain a respiratory rate of 30 or more.
B) The client will describe preventative measure for the underlying chronic illness.
C) The client will maintain baseline cardiac rhythm.
D) The client will remain in a pH range from 7.25 to 7.35.
E) The client will take potassium supplements to increase potassium levels.
The nurse is caring for a client with metabolic acidosis. Which goals are appropriate for this client? Select all that apply.
A) The client will maintain a respiratory rate of 30 or more.
B) The client will describe preventative measure for the underlying chronic illness.
C) The client will maintain baseline cardiac rhythm.
D) The client will remain in a pH range from 7.25 to 7.35.
E) The client will take potassium supplements to increase potassium levels.
The nurse is caring for a client admitted with renal failure and metabolic acidosis. Which clinical manifestation would indicate to the nurse that planned interventions to relieve the metabolic acidosis have been effective? A) Decreased respiratory depth B) Palpitations C) Increased deep tendon reflexes D) Respiratory rate of 38
Answer: A
Explanation: A) The client with metabolic acidosis will have an increased respiratory rate and depth, called Kussmaul respirations. Signs that care has been effective would include a decrease in the rate and depth of respirations. An increased respiratory rate, as indicated by a respiratory rate of 38, would indicate continued metabolic acidosis. Increased deep tendon reflexes and palpitations are not associated with metabolic acidosis.
) The nurse is caring for the client experiencing hypovolemic shock and metabolic acidosis. Which therapies would the nurse question if planned for this client? Select all that apply.
A) Monitor weight on admission and discharge.
B) Monitor ECG for conduction problems.
C) Limit the intake of fluids.
D) Administer sodium bicarbonate.
E) Keep the bed in the locked and low position.
Answer: A, C
Explanation: A) The treatment for hypovolemic shock would include the administration of fluids, not limiting fluids. Patients being treated for hypovolemia and metabolic acidosis will require daily weights, not a weight on admission and then discharge. Administering sodium bicarbonate and monitoring ECGs are appropriate for the client with metabolic acidosis. The client recovering from hypovolemic shock and metabolic acidosis is at risk for injury, so the bed should be kept in the locked and low position.
Answer: A, C
Explanation: A) The treatment for hypovolemic shock would include the administration of fluids, not limiting fluids. Patients being treated for hypovolemia and metabolic acidosis will require daily weights, not a weight on admission and then discharge. Administering sodium bicarbonate and monitoring ECGs are appropriate for the client with metabolic acidosis. The client recovering from hypovolemic shock and metabolic acidosis is at risk for injury, so the bed should be kept in the locked and low position.
Answer: B
Explanation: A) The client with metabolic acidosis may have symptoms of drowsiness, lethargy, confusion, and weakness. A priority of care would be preventing injury to the client. Medication administration is a physician order. Skin care would not be a priority on admission. The high-Fowler position would not be the safest position for the confused client.
The nurse is preparing to teach a client with type 1 diabetes mellitus on the mechanism behind the development of ketoacidosis. List the order in which the nurse should provide this information.
- Production of lactate and hydrogen ions
- Tissue hypoxemia
- Breakdown of fatty tissue
- Reduction in intracellular glucose
- Fatty acids converted to ketones
Answer: 2, 1, 4, 3, 5
Explanation:
Lactic acidosis develops due to tissue hypoxia and a shift to anaerobic metabolism by the cells. Lactate and hydrogen ions are produced, forming lactic acid. Starvation or lack of insulin leads to intracellular starvation of glucose. The lack of glucose or insulin to move glucose into the cells, causing the body to break down fatty tissue to meet metabolic needs. When fatty acids are broken down, these acids are converted to ketones, leading to the development of ketoacidosis.
The nurse identifies the diagnosis Risk for Injury as appropriate for a client with metabolic acidosis. Which strategies should the nurse use to support this diagnosis? Select all that apply.
A) Apply wrist restraints and secure to the bed frame.
B) Discuss chemical restraint use with the healthcare provider.
C) Keep the bed in the lowest position.
D) Keep bed side rails raised.
E) Place a clock and calendar at the bedside.
Answer: C, D, E
Explanation: A) To reduce the client’s risk for injury, the nurse should make sure the bed is kept in the lowest position and the side rails are raised. A clock and calendar at the bedside will help with orientation. Restraints are used in the event the client demonstrates harm to self or others. Confusion or a risk for injury is not a reason to use wrist or chemical restraints.
Upon entering a room, the nurse quickly scans the environment and then immediately assesses the client for manifestations of metabolic acidosis. Which did the nurse observe to precipitate this client assessment?
A) Client sleeping with the head of the bed flat
B) Half of the client’s lunch tray uneaten
C) One formed stool in the bedside commode
D) 2000 mL of intravenous 0.9% normal saline infused in 2 hours
Answer: D
Explanation: A) Excessive infusions of chloride-containing intravenous fluids can precipitate metabolic acidosis. The head of the bed’s being flat might influence a client’s oxygenation status; however, the client was not demonstrating a change in respiratory depth or rate. A reduction in oral intake does not cause metabolic acidosis. Eating half of a meal tray is not the same as starvation. Diarrhea can lead to the development of metabolic acidosis. One formed stool would not cause the nurse alarm.
During a home visit, the nurse evaluates care provided to a client with type 1 diabetes mellitus and a history of metabolic acidosis. Which outcome indicates that the care of this client has been successful?
A) The client is injecting insulin into thigh muscle.
B) The client is taking laxatives three times a week to ensure adequate bowel movements.
C) The client is eating three balanced meals per day with two snacks.
D) The client is taking aspirin 325 mg every 6 hours to treat arthritis pain
Answer: C
Explanation: A) Adequate nutrition is necessary to prevent the buildup of acids in the blood. Incorrect administration of medication could cause a metabolic problem in the client with diabetes. The use of laxatives could cause diarrhea, which can lead to metabolic acidosis. Ingestion of high amounts of salicylate acid can lead to toxicity and the development of metabolic acidosis.
A common cause of metabolic acidosis is
A) hyperventilation in a client with anxiety.
B) high blood glucose in a client with type 1 diabetes.
C) vomiting in a client with a gastrointestinal infection.
D) opiate overdose in a client with depression.
Answer: B
Explanation: A) High blood glucose that leads to diabetic ketoacidosis is a common cause of metabolic acidosis. Vomiting can lead to metabolic alkalosis, hyperventilation can lead to respiratory alkalosis, and opiate overdose can lead to respiratory acidosis.
A compensatory mechanism that may indicate to a nurse that a client is experiencing metabolic acidosis includes: A) headache. B) Kussmaul respirations. C) vomiting. D) decreased level of consciousness
Answer: B
Explanation: A) Kussmaul respirations are deep and rapid respirations that are a compensatory mechanism during metabolic acidosis. Headache, vomiting, and decreased level of consciousness are all clinical manifestations of metabolic acidosis, but they are not compensatory mechanisms that the body uses to maintain acid-base balance during metabolic acidosis.
An alkalinizing solution often given intravenously to clients with severe acute metabolic acidosis is A) sodium bicarbonate. B) sodium chloride. C) potassium chloride. D) dextrose.
Answer: A
Explanation: A) Sodium bicarbonate is an alkalinizing solution often given intravenously to clients with severe acute metabolic acidosis. Sodium chloride and potassium chloride may worsen metabolic acidosis by increasing the chloride concentration. Dextrose may also worsen metabolic acidosis, especially in clients with type 1 diabetes, by increasing blood glucose levels and causing ketoacidosis
The nurse is caring for a 3-month-old infant who presented to the emergency department (ED) with fever, diarrhea, vomiting, and diaper rash over the past 48 hours. Which symptom puts this client most at risk for metabolic acidosis? A) Fever B) Diarrhea C) Vomiting D) Diaper rash
Answer: B
Explanation: A) Infants are more susceptible to metabolic acidosis from diarrhea due to significant losses of bicarbonate in the feces. Vomiting is more likely to result in metabolic alkalosis from loss of stomach acids. Fever and diaper rash do not directly contribute to metabolic acidosis
An older adult client has a history of heart disease and dementia and takes several medications. His wife states that sometimes he forgets to take his medications, or he takes multiple doses of his medications, due to his dementia. An accidental overdose of which medication could result in metabolic acidosis?
A) Losartan (an angiotensin II receptor blocker to reduce hypertension)
B) Simvastatin (a statin to reduce blood cholesterol levels)
C) Rivastigmine (a cholinesterase inhibitor to reduce symptoms of dementia)
D) Aspirin (a salicylate to decrease risk of heart attack)
Answer: D
Explanation: A) Aspirin is salicylic acid, which could decrease the blood pH if taken in high quantities. Diuretics, some antidepressants, antiseizure medications, and angiotensin-converting enzyme (ACE) inhibitors could all affect the acid-base balance in an older adult, but acid-base balance is less affected by angiotensin II receptor blockers, statins, and cholinesterase inhibitors.
The client has been vomiting for several days. The nurse knows that the client is at risk for metabolic alkalosis because gastric secretions have which characteristic?
A) Gastric secretions are green in color.
B) Gastric secretions are alkaline.
C) Gastric secretions are acidic.
D) Gastric secretions have a foul smell.
Answer: C
Explanation: A) Metabolic alkalosis due to loss of hydrogen ions usually occurs because of vomiting or gastric suction. Gastric secretions are highly acidic (pH 1-3). When these are lost through vomiting or gastric suction, the alkalinity of body fluids increases. This increased alkalinity results from the loss of acid and from selective retention of bicarbonate by the kidneys as chloride is depleted. Gastric secretions are not alkaline. The color and odor of gastric secretions have no influence on the development of metabolic acidosis.
The nurse is caring for a client who has been admitted to the hospital for congestive heart failure. Which data collected during the nursing assessment indicate that the client is at risk for metabolic alkalosis? Select all that apply.
A) The client takes furosemide (Lasix) daily.
B) The client takes a baby aspirin once daily.
C) The client takes metformin daily.
D) The client frequently uses calcium carbonate (Tums) for acid indigestion.
E) The client takes acetaminophen as needed for pain.
Answer: A, D
Explanation: A) Excessive use of calcium carbonate and daily use of furosemide can cause metabolic alkalosis. Use of metformin is not associated with alkalosis. Overuse of aspirin can be associated with metabolic acidosis. Occasional use of acetaminophen is not associated with metabolic alkalosis.
An adolescent is hospitalized following several days of vomiting due to food poisoning. The nurse is planning to include which points when teaching the client’s family at discharge? Select all that apply.
A) Immunizations for the adolescent
B) Nutritional patterns of the adolescent
C) Signs and symptoms of metabolic alkalosis
D) Proper food-handling techniques
E) Normal laboratory values of the adolescent
Answer: C, D
Explanation: A) The family of anyone experiencing prolonged vomiting should be taught the signs and symptoms of metabolic alkalosis. In this case, the nurse would include teaching about proper methods of food handling to prevent further episodes of food poisoning. Food patterns of the adolescent are not the precipitating factor of the food poisoning, and immunizations would not prevent this disease. Unless the family asks, it is not necessary to teach normal laboratory findings.
The nurse is planning care for the client who has been admitted with metabolic alkalosis. Which are appropriate nursing diagnoses for this client during the acute phase of the illness? Select all that apply. A) Ineffective Health Maintenance B) Risk for Hypothermia C) Deficient Fluid Volume D) Risk for Impaired Gas Exchange E) Risk for Injury
Answer: C, D, E
Explanation: A) Respiratory compensation for metabolic alkalosis includes depression of the respiratory rate and reduction of the depth of respirations, leading to the retention of carbon dioxide. Patients with metabolic alkalosis often have an accompanying fluid volume deficit. With the fluid volume deficit, the client would experience hyperthermia. Ineffective health maintenance would not be a priority during the acute phase of the disease but, rather, a teaching opportunity before discharge depending on the cause of the metabolic alkalosis. The client is at risk for injury because of the associated muscle spasms and dizziness.
The nurse is planning care for the client with Cushing syndrome who has been admitted for complications related to the disease process. Which intervention should the nurse plan for this client to improve the impaired gas exchange?
A) Monitor serum electrolytes.
B) Schedule nursing activities to allow for periods of rest.
C) Assess input and output accurately.
D) Administer IV fluids per practitioner order
Answer: B
Explanation: A) The client with Cushing syndrome is at risk for developing severe metabolic alkalosis that causes hypoxemia and limits energy reserves. Spacing nursing activities throughout the day allows the client ample rest time. The other interventions are aimed at the deficient fluid volume that may occur with metabolic alkalosis
The nurse is preparing to discharge a client with congestive heart failure on furosemide (Lasix). The nurse determines that teaching has been effective if the client makes which statement?
A) “I will use only sodium bicarbonate as my antacid.”
B) “I will restrict my intake of fluids.”
C) “I will use potassium supplements while I am taking Lasix.”
D) “I will take antacids only for my gastric discomforts.”
Answer: C
Explanation: A) The client on furosemide (Lasix) may lose excess potassium, disposing the client toward metabolic alkalosis. The client is taught to refrain from the use of sodium antacids when prone to metabolic alkalosis. The client should consult with the primary care provider for gastric distress rather than self-medicate. The client who is prone to metabolic alkalosis is likely to have fluid deficits and would not be instructed to restrict fluids.
A client with severe metabolic alkalosis is admitted to the unit. Which is the priority for the client?
A) Administering medication for metabolic alkalosis
B) Monitoring oxygen saturation
C) Teaching the client the risk factors for metabolic alkalosis
D) Setting goals for the client with metabolic alkalosis
Answer: B
Explanation: A) The priority for this client is monitoring oxygen saturation. The depressed respiratory drive that often accompanies metabolic alkalosis can lead to hypoxemia and impaired oxygenation of the tissues. Administering medications will be needed as a treatment, but the priority is to discover the cause. Teaching the client and setting goals are important aspects of nursing care but are not the priority.
A client with hyperaldosteronism is admitted to the unit and is at risk for impaired gas exchange. In which position should this client be placed to enhance gas exchange? A) Fowler position B) Prone position C) Left side-lying position D) Right Sims position
Answer: A
Explanation: A) The client with hyperaldosteronism with metabolic alkalosis will likely have reduced oxygenation. The Fowler position will facilitate alveolar ventilation with improved oxygenation. Side-lying and prone positions do not facilitate needed lung expansion.
While reviewing laboratory results, the nurse notes that a client’s potassium level is 2.8 mEq/L and chloride level is 100 mEq/L. Based on this data, which intervention does the nurse plan for this client?
A) Preparing to administer 0.9% sodium chloride infusion
B) Measuring for nasogastric tube insertion
C) Discussing potassium chloride replacement therapy with the healthcare provider
D) Reviewing implications of transfusing with ammonium chloride
Answer: C
Explanation: A) Treatment of metabolic alkalosis includes restoring normal fluid volume and administering potassium chloride. The potassium restores serum and intracellular potassium levels, allowing the kidneys to conserve hydrogen ions more effectively. Because the chloride level is within normal limits, an infusion of 0.9% sodium chloride is not indicated. A nasogastric tube is not indicated for this client. There is not enough information to support the use of ammonium chloride for this client, as it is indicated to treat severe metabolic alkalosis.
The nurse identifies the diagnosis Risk for Impaired Gas Exchange to guide the care of a client with metabolic alkalosis. Which assessment data supports this nursing diagnosis? Select all that apply. A) Respiratory rate 8 per minute B) Oxygen saturation 89% C) Urine output 25 mL/hr D) Restlessness and agitation E) Weight loss of 3 kg overnight
Answer: A, B, D
Explanation: A) Respiratory compensation for metabolic alkalosis depresses the respiratory rate and reduces the depth of breathing to promote carbon dioxide retention. The depressed respiratory drive associated with metabolic alkalosis can lead to hypoxemia and impaired oxygenation of tissues. Oxygen saturation levels of less than 90% indicate significant oxygenation problems. Changes in mental status or behavior may be early signs of hypoxia. Urine output less than 30 mL/hr would indicate fluid volume deficit. Weight is used as an indicator of fluid balance. A rapid weight change would indicate fluid volume deficit.
A client is admitted with manifestations of metabolic alkalosis. Which diagnostic test findings support the admitting diagnosis? Select all that apply.
A) Serum glucose level 142 mg/dL
B) Blood pH 7.47 and bicarbonate 34 mEq/L
C) Intravenous pyelogram shows kidney stones
D) Bilateral lower lobe infiltrates noted on chest x-ray
E) Electrocardiogram changes consistent with hypokalemia
Answer: B, E
Explanation: A) In metabolic alkalosis, the blood pH will be greater than 7.45 and the bicarbonate level greater than 26 mEq/L. The ECG pattern shows changes similar to those seen with hypokalemia. Serum glucose levels, kidney stones, and lower lobe infiltrates are not associated with metabolic alkalosis.
During an assessment, the nurse becomes concerned that a client is at risk for developing metabolic alkalosis. What did the nurse assess that caused this concern?
A) Daily ingestion of a banana with breakfast
B) Daily weight consistent
C) Daily use of sodium bicarbonate for gastric upset
D) Daily use of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritic pain
Answer: C
Explanation: A) Excess bicarbonate usually occurs as a result of ingesting antacids that contain bicarbonate, such as sodium bicarbonate or Alka-Seltzer. Daily ingestion of a banana would prevent the development of hypokalemia from the daily use of sodium bicarbonate. Consistent daily weights would indicate fluid balance. Daily use of NSAIDs would not support the development of metabolic alkalosis.
During a home visit, the nurse evaluates teaching provided to a client recently hospitalized for metabolic alkalosis. Which observation indicates that additional teaching is required?
A) Drinks 2 cups of black coffee each day.
B) Consumes one orange each day with breakfast.
C) Ingests bicarbonate of soda after each meal.
D) Monitors and tracks daily weights.
Answer: C
Explanation: A) The indiscriminate ingestion of sodium bicarbonate is a risk factor for the development of metabolic alkalosis. Black coffee is not associated with the development of metabolic alkalosis. Oranges contain potassium, which is beneficial to prevent the development of metabolic alkalosis. Tracking of daily weights would help detect a fluid imbalance, which is associated with metabolic alkalosis.
Clinical manifestations of metabolic alkalosis are similar to signs of A) hypocalcemia. B) hypokalemia. C) hypercalcemia. D) hyperkalemia.
Answer: A
Explanation: A) Manifestations of metabolic alkalosis result from decreased calcium ionization and are similar to those of hypocalcemia. They include numbness and tingling around the mouth, fingers, and toes; dizziness; Trousseau sign; and muscle spasm. Clinical manifestations of metabolic alkalosis are not similar to those of hypercalcemia or hyper- or hypokalemia.
A newborn with pyloric stenosis has symptoms of projectile vomiting, leading to significant weight loss, dehydration, and metabolic alkalosis. What client teaching is necessary for the parents in caring for the infant until surgery to correct the defect?
A) Monitoring for hyperventilation to detect changes in health status
B) Breastfeeding techniques to reverse weight loss and dehydration
C) Positioning of the infant to prevent aspiration
D) Performing percussion and postural drainage to clear the airways
Answer: C
Explanation: A) Complications related to aspiration of vomitus can be prevented by correct positioning of the infant. Parents should be taught correct positioning so they can care for the infant at home or when the nurse is not in the room. Hyperventilation leads to respiratory alkalosis and is usually unrelated to pyloric stenosis. Because pyloric stenosis blocks passage of food from the stomach to the small intestines, increasing oral intake will not be beneficial to the infant, so breastfeeding techniques are irrelevant at this time. Percussion and postural drainage are more relevant to lung diseases such as cystic fibrosis, not a gastrointestinal (GI) disorder such as pyloric stenosis.
The nurse assumes care for a client who was brought to the hospital after a morphine overdose. What acid-base imbalance does the nurse expect to observe in this client? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis
Answer: B
Explanation: A) Morphine is a narcotic and generally acts to decrease or suppress respirations; therefore, this client is probably hypoventilating. The expected acid-base imbalance would be respiratory acidosis. Respiratory alkalosis, metabolic acidosis, and metabolic alkalosis are caused by many conditions, none of which are related to this client’s morphine overdose.
The nurse is caring for a client who has been admitted to the unit with respiratory failure and respiratory acidosis. Which data from the nursing history would the nurse suspect contributed to the client’s current state of health?
A) Use of ibuprofen for the control of pain
B) A recent trip to South America
C) Aspiration pneumonia
D) Recent recovery from a cold virus
Answer: C
Explanation: A) Aspiration of a foreign body and acute pneumonia would put the client at risk for respiratory acidosis. A recent trip to South America would not constitute a respiratory risk factor. Recent recovery from a cold would not likely put the client at risk. Ibuprofen does not pose a threat to the respiratory health of the client.
A school-age client is admitted to the hospital with respiratory acidosis. Which chronic lung illness in the client's health history does the nurse suspect is causing the current diagnosis? A) Cystic fibrosis B) Aspiration C) Hyperthyroidism D) Pneumonia
Answer: A
Explanation: A) Chronic lung disease such as asthma and cystic fibrosis put the child at risk for respiratory acidosis. Pneumonia and aspiration are both acute lung conditions. Hyperthyroidism is a disorder that results in metabolic acidosis.
A client is admitted to the unit with chronic obstructive pulmonary disease. Blood gas analysis indicates respiratory acidosis. Based on this data, the nurse plans care based on which priority diagnosis? A) Impaired Gas Exchange B) Ineffective Airway Clearance C) Impaired Mobility D) Anxiety
Answer: A
Explanation: A) Impaired Gas Exchange is the priority nursing diagnosis for the client with respiratory acidosis. Interventions are aimed at restoring effective alveolar ventilation and gas exchange. Anxiety and Ineffective Airway Clearance are both appropriate nursing diagnoses but not priority for the client with respiratory acidosis. There is no evidence to support the nursing diagnosis Impaired Mobility for this client.
The nurse is preparing discharge instructions for an older adult client recovering from respiratory acidosis caused by restrictive lung disease and pneumonia. Which topics should the nurse include in the discharge teaching for this client? Select all that apply.
A) Obtain annual influenza immunization.
B) Engage in frequent hand washing.
C) Avoid crowds.
D) Cover the nose and mouth when coughing.
E) Restrict fluids.
Answer: A, B, C, D
Explanation: A) For the client with a history of chronic lung disease and pneumonia, the nurse should instruct on the importance of receiving annual influenza immunizations, frequent hand washing, avoiding crowds, and covering the nose and mouth when coughing. Fluids should be encouraged to ensure that respiratory secretions are thin.
The nurse is caring for a client who is being mechanically ventilated. The current ventilator settings are: respiratory rate, 25 breaths per minute; tidal volume, 600 mL; FiO2, 30%; humidification 30 mg H2O/L. After being ventilated for 2 hours, arterial blood gas analysis reveals a pH of 7.20 and a PaCO2 of 49 mmHg. Which change in ventilator settings should the nurse anticipate?
A) Increase in humidification of inspired air
B) Decrease of FiO2 from 30% to 25%
C) Increased respiratory rate to 30 breaths per minute
D) Decreased tidal volume of each breath
Answer: C
Explanation: A) This client is exhibiting respiratory acidosis that is not corrected by the current ventilator settings. This client needs to “blow off” more CO2; therefore, the respiratory rate would be increased. Both decreasing the FiO2 and decreasing the tidal volume would decrease the amount of CO2 expelled. Humidification has no effect on the amount of CO2 expelled.
The nurse is preparing to admit a client with acute pneumonia who is experiencing severe respiratory acidosis. Which treatments does the nurse anticipate as appropriate for this client? Select all that apply.
A) Administer oxygen prn.
B) Administer digoxin for heart failure.
C) Encourage up to 3 L of fluids per day.
D) Place in a prone position.
E) Reposition frequently.
Answer: A, C, E
Explanation: A) The client with acute pneumonia and respiratory acidosis may require oxygen administration to improve gas exchange, increased fluid intake to thin secretions, and frequent repositioning to preventing the pooling of respiratory sections. There is not enough evidence to know whether the client is experiencing heart failure as a result of the acute pneumonia. The client should be placed in the Fowler or semi-Fowler rather than the prone position.
The nurse is providing care to a client recently extubated for treatment of aspiration pneumonia and respiratory acidosis. Which action by the nurse provides an optimum environment for this client?
A) Allowing family members to remain with client as much as possible
B) Restraining the client
C) Placing the client in a side-lying position
D) Administering narcotics for pain
Answer: A
Explanation: A) The client with respiratory acidosis often experiences anxiety. This client would benefit from having a family member in the room to provide reassurance. Restraining the client will increase levels of agitation. The client with respiratory failure would benefit most from the semi-Fowler or Fowler position to increase ventilation. Narcotics will depress the respirations and increase respiratory acidosis. A nonnarcotic pain reliever would be considered if this client were experiencing pain.
The nurse is reviewing prescriptions written for a client with chronic respiratory acidosis. Which prescription should the nurse question prior to implementation?
A) Keep head of the bed elevated to 40-degree angle.
B) Dextrose 5% and 0.45% normal saline at 100 mL per hour
C) Consult Respiratory Therapy for breathing treatments four times a day.
D) Oxygen 6 liters per minute per nasal cannula
Answer: D
Explanation: A) In clients with chronic respiratory acidosis, oxygen is administered cautiously to prevent carbon dioxide narcosis. Adequate hydration such as intravenous fluids is important to promote removal of respiratory secretions. Pulmonary hygiene measures such as breathing treatments may be instituted. Elevating the head of the bed promotes oxygenation.
A client with pneumonia develops respiratory acidosis. Based on provider’s orders, which medications should the nurse prepare to administer to this client? Select all that apply.
A) The loop diuretic furosemide (Lasix), 20 mg by mouth twice a day
B) The antibiotic amoxicillin, 1 gram intravenous every 6 hours
C) The bronchodilator albuterol, inhaler 2 puffs every 4 hours
D) The anxiolytic diazepam (Valium), 2 mg by mouth at bedtime for sleep
E) Potassium chloride 20 mEq in 100 mL 0.9% normal saline intravenous every day
Answer: B, C
Explanation: A) Bronchodilator drugs such as an albuterol inhaler may be administered to open the airways, and antibiotics such as amoxicillin may be prescribed to treat respiratory infections. Benzodiazepines such as diazepam are central nervous system depressants and would adversely affect this client’s respiratory rate, adversely affecting respiratory acidosis. Potassium chloride is indicated in the treatment of metabolic alkalosis.
A client is admitted to the emergency department (ED) for treatment of an overdose. The client's arterial blood gas results indicate acute respiratory acidosis. Which substance found on the nurse's review of the toxicology analysis is most likely the cause for the client's current condition? A) Cocaine (a stimulatory anesthetic) B) Marijuana (a cannabinoid) C) Oxycodone (a narcotic) D) PCP (a dissociative anesthetic)
Answer: C
Explanation: A) Oxycodone is an opiate narcotic. Excessive use or overdose of narcotic substances can lead to respiratory depression and respiratory acidosis. Cocaine is a stimulant. Marijuana does not depress the central nervous system or respiratory center. PCP is a hallucinogenic agent.
The nurse suspects a client with one functioning lung is developing chronic respiratory acidosis. Which manifestation did the nurse most likely assess in this client? A) Warm, flushed skin B) Daytime sleepiness C) Irritability D) Blurred vision
Answer: B
Explanation: A) The manifestations of acute and chronic respiratory acidosis differ. The client with chronic respiratory acidosis will demonstrate daytime sleepiness. The client with acute respiratory acidosis may demonstrate warm, flushed skin, irritability, and blurred vision from the acute decline in oxygenation.
The nurse instructs a client with a history of acute respiratory acidosis and lung infections on ways to prevent further episodes of the health problem. Which client statement indicates that teaching has been effective?
A) “I will limit drinking alcohol to the evening hours only.”
B) “I will limit my intake of bananas and oranges.”
C) “I will take prescribed antibiotics until my symptoms subside.”
D) “I will receive the annual influenza vaccination.”
Answer: D
Explanation: A) The nurse should discuss ways to avoid future episodes of acute respiratory infections by encouraging the client to receive immunization against pneumococcal pneumonia and influenza. Alcohol is a central nervous system depressant, which can adversely affect respiratory status and lead to the development of respiratory acidosis. The ingestion of bananas and oranges will not promote the development of respiratory acidosis. The client should be instructed to complete a full course of antibiotics prescribed to treat infections.
The nurse is planning care for an older client with respiratory acidosis. Which intervention should the nurse include in this client’s plan of care?
A) Administer prescribed intravenous fluids carefully.
B) Administer intravenous sodium bicarbonate.
C) Maintain adequate hydration.
D) Reduce environmental stimuli.
Answer: C
Explanation: A) In respiratory acidosis, there are a drop in the blood pH, a reduced level of oxygen, and retention of carbon dioxide. The body needs to be well-hydrated so that pulmonary secretions can be removed to improve oxygenation. Careful administration of intravenous fluids is important in the older client with metabolic alkalosis because older clients are at risk because of their fragile fluid and electrolyte status. Sodium bicarbonate is indicated in the treatment of metabolic acidosis. Reducing environmental stimuli would be appropriate for the client with respiratory alkalosis.
Acute respiratory acidosis can lead to \_\_\_\_\_\_\_\_, which affects neurological function and the cardiovascular system. A) hypercapnia B) carbon dioxide narcosis C) hypoventilation D) hyperventilation
Answer: A
Explanation: A) In acute respiratory acidosis, increased carbon dioxide levels, also called hypercapnia, can affect neurological function and the cardiovascular system. Carbon dioxide narcosis occurs in chronic respiratory acidosis. Hypoventilation causes respiratory acidosis; it doesn’t result from respiratory acidosis. Hyperventilation is related to respiratory alkalosis, not respiratory acidosis
