Chapter 8 PrepU
A client admitted to the hospital with severe diarrhea has a K+ level of 6.7 mEq/L (6.7 mmol/L) and symptoms of paresthesia, restlessness, and dyspnea. Arterial blood gases reveal a low pH level. Which intervention will the nurse anticipate administering to correct this condition? A)Oxygen B)Intravenous (IV) insulin C)Antidiarrheal drugs D)Antibiotics
B) Intravenous (IV) insulin Explanation: In metabolic acidosis, H+ moves into body cells for buffering, causing K+ to leave and move into the extracellular fluid. Both insulin and the catecholamines (e.g., epinephrine) increase cellular uptake of K+ by increasing the activity of the Na+/K+-ATPase membrane pump. Insulin produces an increase in the cellular uptake of potassium.
A client has these arterial blood gas values: anion gap 20 mEq/L (20 mmol/L), pH 7.29, PCO2 37 mm Hg (4.92 mmol/L), HCO3- 11 mEq/L (11 mmol/L), base excess -6 mEq/L (-6 mmol/L). With what condition do these values correspond? A) Hyperkalemia B) Lactic acidosis C) lithium toxicity D) Multiple myeloma
B) Lactic acidosis Explanation: Anion gap (AG) is the difference between the plasma concentration of sodium ions and the sum of the measured anions (chloride and bicarbonate). Normally, the AG value should be between 8 and 16 mEq/L. AG will rise above normal for conditions that commonly cause acidosis such as lactic acidosis and ketoacidosis. Hyperkalemia, lithium toxicity, hypercalcemia, hypermagnesemia, and multiple myeloma will cause a drop in the AG by raising the level of unmeasured cations. ABGs measure pH, carbon dioxide (PCO2), bicarbonate ion (HCO3-), oxygen (PO2), base excess, and the anion gap. A pH that is below 7.35 is considered acidic. The PCO2 is the primary indicator of respiratory function and falls between 35 and 45mm Hg. Bicarbonate (HCO3-) is the primary indicator of metabolic function and is acidic if below 22 mEq/L. Base excess measures the level of all the buffer systems in the blood. If the level is more than 0.2 mEq/L below the normal pH of 7.4 it is considered deficit and indicates metabolic acidosis.
A client develops interstitial edema as a result of decreased: A)Vascular volume B)Colloidal osmotic pressure C)Capillary permeability D)Hydrostatic pressure
B)Colloidal osmotic pressure Explanation: Edema can be defined as palpable swelling produced by an increased interstitial fluid volume. The physiologic mechanisms that contribute to edema formation include factors that (1) increase capillary filtration (hydrostatic) pressure, (2) decrease the capillary colloid osmotic pressure, (3) increase capillary permeability, or (4) produce obstruction to lymph flow.
The nurse is caring for a client with acute primary respiratory acidosis. When determining the cause of the acidosis the nurse is aware that which imbalance is most common? A)Decreased CO2 retention B)Impaired alveolar ventilation C)Renal bicarbonate retention D)Increased metabolic acids
B)Impaired alveolar ventilation Explanation: Acute respiratory acidosis is frequently caused by impaired alveolar ventilation with CO2 retention. Increased metabolic acids, such as lactic acid, are characteristic of metabolic acidosis. Bicarbonate retention is a compensatory response to respiratory acidosis, or it can be the cause of metabolic alkalosis when retention is excessive.
The nurse is caring for a client who has consistently been vomiting throughout several days. What will the nurse expect to find when evaluating the client's blood gas values? A)Increased PCO2 values B)Increased pH value C)Decreased bicarbonate values D)No change in blood gas values
B)Increased pH value Explanation: The client who is vomiting will be expected to lose gastric acid, resulting in a metabolic alkalosis. The client's PCO2 would not be expected to increase.
A client presents to the emergency department with delirium. Laboratory results reveal sodium level of 123 mEq/L (123 mmol/L). The physician orders fluid replacement with hypertonic IV solution, 20 mg furosemide, and intravenous pyelogram. Which result would the nurse expect? A)Development of central pontine myelinolysis B)Intracellular dehydration, increase sodium levels, and removal of excess body water C)Decreased extracellular fluid volume, decrease in sodium level, increase in serum potassium D)Increased extracellular fluid volume and an increase in sodium level
B)Intracellular dehydration, increase sodium levels, and removal of excess body water Explanation: Symptomatic hyponatremia (i.e., neurologic manifestations) is often treated with hypertonic saline solution and a loop diuretic, such as furosemide, to increase water elimination. This combination allows for correction of plasma sodium levels while ridding the body of excess water. One complication of rapid treatment of hyponatremia is an osmotic demyelinating condition called central pontine myelinolysis, which produces serious neurologic sequelae and sometimes causes death. This is not an expectation of treatment.
The client with a small bowel obstruction has a nasogastric tube set to low, continuous suction. The nurse explains that this treatment places the client at risk for: A)Metabolic acidosis B)Metabolic alkalosis C)Respiratory alkalosis D)Respiratory acidosis
B)Metabolic alkalosis Explanation: Metabolic alkalosis can be caused by factors that generate a loss of fixed acids, such as from the stomach by gastric suction.
The nurse is assessing a client with abnormal blood gas values. Which of these interpretations does the nurse make regarding the client's physiologic status? A)The client has alterations in vital signs. B)The client has abnormalities in his buffer system. C)The client has a decreased hemoglobin. D)The client has abnormalities in his cardiovascular system.
B)The client has abnormalities in his buffer system. Explanation: The client with an abnormal blood gas may have abnormalities in his respiratory, renal, or chemical buffer system. These systems assist in regulating blood gases. Hemoglobin, vital signs, and the cardiovascular system are not direct buffers for this system. The only assumption the nurse can make is that there is a problem with the buffer system.
The physician is treating a client in lactic acidosis following cardiac arrest. Which treatment will be effective in correcting this acidosis? A)Administration of sodium bicarbonate B)Treatments to improve tissue perfusion and oxygenation C)Hypoventilation D)Administration of potassium chloride
B)Treatments to improve tissue perfusion and oxygenation Explanation: In most people with circulatory shock, cardiac arrest, or sepsis, impaired oxygen delivery is the primary cause of lactic acidosis. In these situations, the administration of large amounts of sodium bicarbonate does not improve oxygen delivery. With lactic acidosis, treatment measures to improve tissue perfusion are necessary. Administration of potassium chloride is used in the treatment of metabolic alkalosis. Hypoventilation is also used in alkalotic states.
A client with a brain tumor develops hyperpnea. What ABG values would the nurse expect to obtain? A)pH 7.41, PCO2 39mm Hg (5.19 kPa), HCO3- 23 mEq/L (23 mmol/L), PO2 91mm Hg (12.10 kPa) B)pH 7.56, PCO2 31mm Hg (4.12 kPa), HCO3- 22 mEq/L (22 mmol/L), PO2 99mm Hg (13.17 kPa) C)pH 7.29, PCO2 67mm Hg (8.91 kPa), HCO3- 26 mEq/L (26 mmol/L), PO2 64mm Hg (8.51 kPa) D)pH 7.32, PCO2 45mm Hg (5.99 kPa), HCO3- 18 mEq/L (18 mmol/L), PO2 85mm Hg (11.30 kPa)
B)pH 7.56, PCO2 31mm Hg (4.12 kPa), HCO3- 22 mEq/L (22 mmol/L), PO2 99mm Hg (13.17 kPa) Explanation: When a client develops hyperpnea, whether from a panic attack, high ventilator settings, or a condition that increases respiratory rate, the rate of excretion of carbon dioxide increases. This creates respiratory alkalosis.
The nurse in the labor and delivery unit is administering intravenous magnesium to a client with preeclampsia. For which complication does the nurse monitor the client? A) Hypertension B) Muscle Contraction C) Cardiac dysrhythmias D) induce labor
C) Cardiac dysrhythmias Explanation: Hypermagnesemia affects neuromuscular and cardiovascular function. Increased magnesium decreases acetylcholine release at the myoneural junction, causing hyporeflexia, muscle weakness, a calcium channel-blocking effect. Blood pressure is decreased, and electrocardiographic changes occur. Severe hypermagnesemia may cause muscle and respiratory paralysis, complete heart block, and cardiac arrest. The other complications listed are related to low magnesium levels.
A client with renal failure and severe hyperkalemia (K+ level 7.2 mEq/L [7.2 mmol/L]) has just been admitted to the nursing unit. The nurse anticipates administering which treatment to quickly lower potassium levels? A) Hydromorphone via patient-controlled anesthesia (PCA) device to control pain B) Infusion of methylprednisolone to decrease irritation to intravascular system C) Short-acting insulin with glucose given intravenously as a bolus D) Lactated Ringer's solution at 150 ml/hr to maintain blood glucose levels
C) Short-acting insulin with glucose given intravenously as a bolus Explanation: The administration of sodium bicarbonate, β-adrenergic agonists, or insulin bolus with gluose distributes potassium into the intracellular fluid compartment and rapidly decreases the extracellular fluid concentration. Glucose level must be monitored to prevent rebound hypoglycemia. Lactated Ringer's solution, steroids, or narcotics will not help with lowering potassium levels.
Which individuals would be considered to be at risk for the development of edema? Select all that apply. A)A client with hypoalbuminemia secondary to malnutrition and anorexia nervosa B)A client with a diagnosis of poorly controlled diabetes mellitus C)A client with right-sided heart failure and hypothyroidism D) A client who has an active gastrointestinal bleed and consequent anemia E) A client who has suffered extensive burns in a job-related accident
C)A client with right-sided heart failure and hypothyroidism E)A client who has suffered extensive burns in a job-related accident A)A client with hypoalbuminemia secondary to malnutrition and anorexia nervosa Explanation: Right-sided heart failure, burns, and low levels of plasma proteins are all associated with the development of edema. Diabetes and GI bleeds are not identified as contributing to edema.
A nurse is caring for a client admitted with diabetic ketoacidosis who is being treated with intravenous (IV) insulin administration. The client develops symptoms of anorexia, nausea, vomiting, constipation, and abdominal distention. Bowel sounds are hypoactive. Based on these symptoms, which electrolyte alteration should the nurse monitor for? A)Hypophosphatemia B)Hypocalcemia C)Hypokalemia D)Hypernatremia
C)Hypokalemia Explanation: Insulin increases the movement of glucose and potassium into cells; therefore, potassium deficit often develops during treatment of diabetic ketoacidosis.
The body has built-in compensatory mechanisms that take over when correction of pH is not possible or cannot be immediately achieved. What are these compensatory mechanisms considered? A)Short-term measures that depend on first-line correction mechanisms B)Long-term measures that back up first-line correction mechanisms C)Interim measures that permit survival while body tries to correct the primary problem D)Ways to correct the primary disorder
C)Interim measures that permit survival while body tries to correct the primary problem Explanation: Often, compensatory mechanisms are interim measures that permit survival while the body attempts to correct the primary disorder.
The nurse is assessing a client who is receiving mechanical ventilation. Which assessment data obtained by the nurse may indicate that the client is experiencing respiratory alkalosis? A)Negative Trousseau sign B)Hypotonia C)Positive Chvostek sign D)Negative Homans sign
C)Positive Chvostek sign Explanation: The signs and symptoms of respiratory alkalosis are associated with hyperexcitability of the nervous system and a decrease in cerebral blood flow. If responsive and able to speak, the client may complain of light-headedness, dizziness, tingling, and numbness of the fingers and toes. Sweating, palpitations, panic, air hunger, and dyspnea may accompany these manifestations. Chvostek and Trousseau signs may be positive and tetany and convulsions may occur.
The nurse is teaching the client about Vitamin D. Which of these topics should the nurse include in the teaching plan? Select all that apply. A)Vitamin D is transported to the kidneys. B)Absorption of calcium from the intestine increases. C)Vitamin D is present in the skin or intestine. D) Calcitriol is produced E) Vitamin D is concentrated in the brain.
C)Vitamin D is present in the skin or intestine. B)Absorption of calcium from the intestine increases. A)Vitamin D is transported to the kidneys. D)Calcitriol is produced Explanation: Vitamin D is either synthesized in the skin by ultraviolet exposure or obtained from the intestines following ingestion. It is then concentrated in the liver and transported to the kidneys.
The nurse and nursing student are caring for a client with end-stage renal disease (ESRD) whose blood gases reveal acidosis. The student notes the respiratory rate is 36 breaths/min. The nurse mentor explains that the rationale for this respiratory rate includes which concept? A)Kidneys are not able to buffer the acid and require help from the lungs. B)Chemoreceptors notice the pH change and increase the ventilation rate. C)Kidneys are trying to excrete excess hydrogen from the lungs. D)Anxiety level is high and the body is trying to release endorphins.
Chemoreceptors notice the pH change and increase the ventilation rate. Explanation: The second line of defense against acid-base disturbances is the control of extracellular CO2 by the lungs. Blood PCO2 and pH are important regulators of ventilation. Chemoreceptors in the brain stem and the peripheral chemoreceptors in the carotid and aortic bodies sense changes in PCO2 and pH and alter the ventilatory rate.
A nurse is caring for a client with a low sodium level and increased water retention. Hematocrit and blood urea nitrogen levels are decreased, urine osmolality is high, and serum osmolality is low. A chest x-ray shows a possible lung mass. Based on these findings, which problem could the client be diagnosed with? A)Diabetes insipidus B)Liver disease with ascites C)Hyperglycemia D)Syndrome of inappropriate antidiuretic hormone (SIADH)
D) Syndrome of inappropriate antidiuretic hormone (SIADH) Explanation: The syndrome of inappropriate ADH (SIADH) results from a failure of the negative feedback system that regulates the release and inhibition of ADH. In people with this syndrome, ADH secretion continues even when serum osmolality is decreased, causing marked water retention and dilutional hyponatremia. SIADH may occur as a transient condition, as in a stress situation, or, more commonly, as a chronic condition, resulting from disorders such as lung or brain tumors. Tumors, particularly bronchogenic carcinomas and cancers of the lymphoid tissue, prostate, and pancreas, are known to produce and release ADH independent of normal hypothalamic control mechanisms. The manifestations of SIADH are those of dilutional hyponatremia. Urine osmolality is high and serum osmolality is low. Urine output decreases despite adequate or increased fluid intake. Hematocrit and the plasma sodium and blood urea nitrogen levels are all decreased because of the expansion of the extracellular fluid volume.
The sodium-phosphate cotransporter (NPT2) creates the action by which phosphate is reabsorbed from the filtrate in the proximal tubule. Which condition can cause an overproduction of phosphatonin resulting in hypophosphatemia? A)Tumor-induced syndrome of antidiuretic hormone B)Tumor-induced hypopituitarism C)Tumor-induced osteomyelitis D)Tumor-induced osteomalacia
D) Tumor-induced osteomalacia Explanation: The NPT2 is also inhibited by the recently identified hormone called phosphatonin. When this hormone is overproduced, as in tumor-induced osteomalacia, marked hypophosphatemia occurs. The other conditions are not caused by hypophosphatemia.
A client has developed ascites secondary to alcoholism. The client's abdominal girth is increased because: A)a damaged liver swells and eventually fills the abdomen. B)the damage to the liver inhibits the excretion of water. C)toxin accumulation drives the retention of water. D)the liver no longer produces enough plasma proteins to maintain osmotic pressure.
D) the liver no longer produces enough plasma proteins to maintain osmotic pressure. Explanation: Plasma proteins exert the osmotic force needed to pull fluid back into the capillary from the tissue spaces. The plasma proteins constitute a mixture of proteins, including albumin, globulins, and fibrinogen. The liver does not excrete water, nor does it swell due to alcoholism. Toxin accumulation has a minimal effect on water retention.
A client develops interstitial edema as a result of decreased: A)Vascular volume B)Capillary permeability C)Hydrostatic pressure D)Colloidal osmotic pressure
D)Colloidal osmotic pressure Explanation: Edema can be defined as palpable swelling produced by an increased interstitial fluid volume. The physiologic mechanisms that contribute to edema formation include factors that (1) increase capillary filtration (hydrostatic) pressure, (2) decrease the capillary colloid osmotic pressure, (3) increase capillary permeability, or (4) produce obstruction to lymph flow.
A client staggers into the emergency department with his son who states that his father has not been well for a couple of weeks. The client's heart rate is 120 and lung sounds reveal crackles and a respiratory rate of 30. The client also reports right flank pain. The son says that his mother has been acting strangely and thinks she might be poisoning her husband. Which clinical manifestation indicates the type of poisoning involved? A)Salicylates B)Sodium bicarbonate C)Digitalis toxicity D)Ethylene glycol (antifreeze)
D)Ethylene glycol (antifreeze) Explanation: Ethylene glycol is a solvent found in products ranging from antifreeze and de-icing solutions to carpet and fabric cleaners. It tastes sweet and is intoxicating, factors that contribute to its abuse potential. It is the leading cause of death from a chemical agent in the United States. Manifestations of ethylene glycol toxicity occur in four stages: neurologic symptoms, cardiorespiratory disorders, flank pain, and acute renal failure.
A 77-year-old woman has been brought to the emergency department by her daughter because of a sudden and unprecedented onset of confusion. The client admits to ingesting large amounts of baking soda this morning to treat some "indigestion." How will the woman's body attempt to resolve this disruption in acid-base balance? A)Increase the depth of inspiration B)Increased renal HCO3- reabsorption C)Increasing renal H+ excretion D)Hypoventilation
D)Hypoventilation Explanation: When neurologic manifestations occur with metabolic alkalosis, they include mental confusion, hyperactive reflexes, tetany, and carpopedal spasm. Respiratory compensation will take place in an effort to counteract the client's metabolic alkalosis. This will involve hypoventilation. In addition, her kidneys are likely to decrease H+ excretion and HCO3- reabsorption.
What information will the nurse need to know in order to calculate a client's anion gap (AG)? Select all that apply. A)Proteins B)Bicarbonate C)Chloride D)Sodium E)Sulfates
D)Sodium C)Chloride B)Bicarbonate Explanation: The anion gap is a diagnostic concept that describes the difference between the plasma concentration of the major measured cation sodium (Na+) and the sum of the measured anions chloride and bicarbonate (Cl- and HCO3-). The difference represents the concentration of unmeasured anions such as phosphates, sulfates, organic acid, and proteins.
A client has been diagnosed with respiratory alkalosis. What assessment finding should the nurse anticipate? Select all that apply. A)HCO3- 27 mEq/L (27 mmol/L) B)PCO2 34 mm/hg (4.52 kPa) C)PCO2- 45 mm/hg (5.99 kPa) D)pH above 7.45 E)HCO3- 19 mEq/L (19 mmol/L)
D)pH above 7.45 B)PCO2 34 mm/hg (4.52 kPa) E)HCO3- 19 mEq/L (19 mmol/L) Explanation: The pattern of blood gas values the nurse expects with respiratory alkalosis is an increased pH above 7.45 and a decreased PCO2 below 35 mm/hg. The HCO3 does not play a role in respiratory disorders but may be decreased as a compensatory mechanism.
A nurse is reviewing laboratory values for an older adult client admitted for changes in mental status. The laboratory values are a urine-serum ratio of 4:1 and urine osmolality of 1100 mOsm/kg H2O. Based on these lab results, the nurse anticipates treatment for which problem? Dehydration Renal failure Urinary tract infection Diabetes insipidus
Dehydration Explanation: A dehydrated person (one who has had a loss of water) may have a urine-serum ratio that approaches 4:1. In these persons, urine osmolality may exceed 1000 mOsm/kg H2O.
Which diagnostic signs might be seen in a client whose serum calcium level is 7.1 mg/dL? Select all that apply. A)Chandelier B)Homan C)Chevostek D)Chadwick E)Trousseau
E)Trousseau C)Chevostek Explanation: A serum calcium level of 7.1 mg/dL indicates hypocalcemia. Chevostek and Trousseau tests can be used to assess for increased neuromuscular excitability that is associated with hyocalcemia. Chevostek sign is elicited by tapping the face just below the temple at the point where the facial nerve emerges. Tapping the face over the facial nerve causes spasm of the lip, nose, or face when the test is positive. An inflated blood pressure cuff is used to test for Trousseau sign. The cuff is inflated 10 mm Hg above the systolic blood pressure for 3 minutes. Contraction of the fingers and hands indicates the presence of tetany. The other signs are not related to serum calcium levels.
A client has an increase in her anion gap (AG). What does the nurse determine is the significance of this finding? It indicates the client has metabolic alkalosis. It indicates the client has respiratory alkalosis. It indicates the client has respiratory acidosis. It indicates the client has metabolic acidosis.
It indicates the client has metabolic acidosis. Explanation: Increased anion gap is found in conditions such as lactic acidosis or ketoacidosis or other conditions leading to metabolic acidosis. The other answers are incorrect as they do not relate to metabolic acidosis.
The nurse is working with a client who lives with chronic metabolic acidosis. Which intervention best addresses the most likely etiology of this client's health problem? A)Hemodialysis B)Chest physiotherapy C)Administering antiemetics D)Educating the client on the safe use of analgesics
A) Hemodialysis Explanation: Chronic kidney disease is the most common cause of chronic metabolic acidosis. As such, hemodialysis is the most plausible and likely intervention that addresses this acid-base disorder. Vomiting causes alkalosis, not acidosis, so antiemetics would be ineffective. Respiratory etiologies are uncommon in chronic metabolic acidosis, so chest physiotherapy would not be effective. Inappropriate use of analgesics, especially salicylates, is a more likely cause of acute metabolic acidosis.
The client with a small bowel obstruction has a nasogastric tube set to low, continuous suction. The nurse explains that this treatment places the client at risk for: A)Metabolic alkalosis B)Respiratory acidosis C)Respiratory alkalosis D)Metabolic acidosis
A) Metabolic alkalosis Explanation: Metabolic alkalosis can be caused by factors that generate a loss of fixed acids, such as from the stomach by gastric suction.
Which one of the following is associated with hydrostatic edema? A)Pits to finger pressure B)Lymphatic obstruction C)Increased plasma osmotic pressure D)High protein content
A) Pits to finger pressure Explanation: Hydrostatic pressure is pressure pushing water out of the capillary and into interstitial spaces. Pitting edema occurs when the accumulation of interstitial fluids exceeds the absorptive capacity of the tissue gel. In this form of edema, the tissue water becomes mobile and can be translocated with the pressure exerted by a finger.
A client is brought to the emergency department reporting shortness of breath. Assessment reveals a full, bounding pulse; severe edema; and audible crackles in lower lung fields bilaterally. Which action by the nurse is most appropriate? A)Administer diuretics as ordered. B)Arrange for a STAT electrocardiogram. C)Administer hypertonic IV solution as ordered. D)Administer IV solution containing potassium as ordered.
A)Administer diuretics as ordered. Explanation: Peripheral and pulmonary edema, as well as a bounding pulse and dyspnea, are indicators of fluid volume overload. Diuresis is often necessary. IV solutions may exacerbate the client's problem and there is no immediate indication of cardiac involvement.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone as a result of an inoperable brain tumor. When assessing the laboratory results for this client, which finding does the nurse anticipate? A)Increase in urine osmolality B)Increase in BUN C)Increase in serum osmolality D)Increase in hematocrit
A)Increase in urine osmolality Explanation: The manifestations of SIADH are those of dilutional hyponatremia. Urine osmolality is high and serum osmolality is low. Urine output decreases despite adequate or increased fluid intake. Hematocrit and the plasma sodium and BUN levels are all decreased because of the expansion of the ECF volume. The diagnosis of SIADH should be considered only if the five cardinal features are fulfilled: (1) hypotonic hyponatremia, (2) natriuresis, (3) urine osmolality in excess of plasma osmolality, (4) absence of edema and volume depletion, and (5) normal renal, thyroid, and adrenal function.
The edema of venous thrombosis (thrombophlebitis) is related to which of the following? A)Increased capillary pressure B)decreased capillary colloidal osmotic pressure C)increased capillary permeability D)obstruction to lymph flow
A)Increased capillary pressure Explanation: Thrombophlebitis obstructs venous flow, producing an elevation of the venous pressure and edema of the affected part, usually one of the lower extremities.
A client who has just had her first postoperative dinner out to celebrate her recovery from an intestinal bypass is brought to the emergency room by her spouse. He reports that his wife seems disoriented and is slurring her words. The client did not have any alcohol with her pasta dinner. What might be the cause of her symptoms? A)Lactic acidosis B)Hypercapnia C)Hypothalemia D)Ketoacidosis
A)Lactic acidosis Explanation: A unique form of lactic acidosis, called D-lactic acidosis, can occur in persons with intestinal disorders that involve the generation and absorption of D-lactic acid. D-lactic acidosis can occur in persons with jejunoileal bypass, in which there is impaired reabsorption of carbohydrate in the small intestine. Persons with D-lactic acidosis experience episodic periods of metabolic acidosis often brought on by eating a meal high in carbohydrates. Manifestations include confusion, cerebellar ataxia, slurred speech, and loss of memory. They may complain of feeling (or may appear) intoxicated.
The nurse is assessing a client with fluid volume deficit. Which manifestation of fluid volume deficit may be observed? Select all that apply. A) Prolonged capillary refill B) Decreased urine output C) Bounding pulse D) Sunken eyes E) Hypertension
A)Prolonged capillary refill B)Decreased urine output D)Sunken eyes Explanation: Manifestations of fluid volume deficit reflect a decrease in extracellular fluid volume and include signs of water conservation by the kidney, decreased vein filling, and sunken eyes. Blood pressure decreases and the pulse becomes weak and thready.
The nurse caring for a client with respiratory alkalosis examines arterial blood gas (ABG) results. Which change from the initial value indicates the client's respiratory alkalosis is improving? A)pH has decreased B)HCO3- has increased C)O2 has increased D)CO2 has decreased
A)pH has decreased Explanation: In respiratory alkalosis, the client has a net loss of carbon dioxide (CO2) which creates a rise in pH. The pH needs to move away from alkalosis, which is the high end of the pH scale, for the client's condition to demonstrate improvement. To lower the pH, either the carbon dioxide (CO2) level needs to increase or the bicarbonate level needs to decrease. Oxygen (O2) concentration is reported on ABG results, but does not indicate acid-base balance.
By reabsorbing HCO3- from the glomerular filtrate and excreting H+ from the fixed acids that result from lipid and protein metabolism, the kidneys work to return or maintain the pH of the blood to normal or near-normal values. How long can this mechanism function when there is a change in the pH of body fluids? A)Days B)Hours C)Minutes D)Weeks
A) Days Explanation: The renal mechanisms for regulating acid-base balance cannot adjust the pH within minutes, as respiratory mechanisms can, but they continue to function for days, until the pH has returned to normal or near-normal range. It is the respiratory system that responds within minutes to return the body's pH near to its normal limits.
A child has been admitted to the emergency department after consuming ethylene glycol in the form of antifreeze. The nurse should prioritize which goal when planning the client's care? A)The client will remain free from the effects of metabolic acidosis. B)The client will maintain a respiratory rate between 10 and 16 breaths per minute. C)The client will demonstrate respiratory compensation for metabolic alkalosis. D)The client's arterial blood pH will remain between 7.15 and 7.25.
A) The client will remain free from the effects of metabolic acidosis. Explanation: Ethylene glycol ingestion causes metabolic acidosis. Normal blood pH is 7.35 to 7.45. Bradypnea would not benefit the client, and has the potential to inhibit respiratory compensation.
Which buffer system acts immediately? A)Chemical buffer systems B)Phosphate buffer systems C)Respiratory control mechanisms D)Renal control mechanisms
A)Chemical buffer systems Explanation: The chemical buffer systems act immediately, the respiratory control mechanisms within minutes, and the renal control mechanisms within hours. The phosphate buffer system is part of the renal control mechanisms.
The nurse is caring for a client with diabetic ketoacidosis. Which assessment finding is characteristic of metabolic acidosis? A)Deep and rapid respirations B)Deep inspirations followed by shallow expirations. C)Shallow but rapid respirations D) Apnea followed by hyperpnea
A)Deep and rapid respirations Explanation: The respiratory system compensates for a decrease in pH by reducing PCO2 with deep and rapid respiration. This breathing pattern is referred to as Kussmaul breathing.
When caring for a client with hypomagnesemia, the nurse evaluates electrolytes that are commonly associated with which condition? A)Hypocalcemia B)Hyperphosphatemia C)Hypercalcemia D)Hypophosphatemia
A)Hypocalcemia Explanation: Hypocalcemia is typically seen in clients with severe hypomagnesemia. Magnesium acts as a cofactor in many intracellular enzyme reactions, including the transfer of high-energy phosphate groups in the generation of adenosine triphosphate from adenosine diphosphate. Phosphorus levels are not affected by magnesium imbalance.
The nurse is caring for a client who takes lithium for his bipolar disorder. The nurse carefully observes the client for which potential electrolyte imbalance? A)Hyperkalemia B)Hypernatremia C)Hyperphosphatemia D)Hypercalcemia
D) Hypercalcemia Explanation: The use of lithium to treat bipolar disorders has been shown to cause hyperparathyroidism and hypercalcemia.
The syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by: A) increased osmolality level of 360 mOsm/kg (360 mmol/kg). B) copious dilute urination with output of 5000 mL/day C) excessive thirst with fluid intake of 7000 mL/day D) Low serum sodium level of 122 mEq/L (122 mmol/L)
D) Low serum sodium level of 122 mEq/l Explanation: SIADH results from a failure of the negative feedback system that regulates the release and inhibition of antidiuretic hormone (ADH). ADH secretion continues even when serum osmolality is decreased, causing water retention and dilutional hyponatremia. Diabetes insipidus, deficiency, or decreased response to ADH is characterized by increased serum osmolality, excessive thirst, and polyuria. Urine output decreases in SIADH despite adequate or increased fluid intake.
A client with ethylene glycol toxicity is restless, and stating he has flank pain. What intervention should the nurse perform to minimize complications? A)Give aspirin for pain B)Reduce dietary calcium C)Encourage ambulation D)Increase IV fluids
Increased capillary pressure Explanation: Thrombophlebitis obstructs venous flow, producing an elevation of the venous pressure and edema of the affected part, usually one of the lower extremities.
A client admitted to the hospital with severe diarrhea has a K+ level of 6.7 mEq/L (6.7 mmol/L) and symptoms of paresthesia, restlessness, and dyspnea. Arterial blood gases reveal a low pH level. Which intervention will the nurse anticipate administering to correct this condition? Oxygen Antibiotics Antidiarrheal drugs Intravenous (IV) insulin
Intravenous (IV) insulin Explanation: In metabolic acidosis, H+ moves into body cells for buffering, causing K+ to leave and move into the extracellular fluid. Both insulin and the catecholamines (e.g., epinephrine) increase cellular uptake of K+ by increasing the activity of the Na+/K+-ATPase membrane pump. Insulin produces an increase in the cellular uptake of potassium.
A client arrives in the emergency department by ambulance with a family member stating, "He took an overdose of sleeping pills and I found him breathing very shallowly." For which type of acid-base disturbance will the nurse anticipate this client will be treated? Metabolic acidosis Respiratory acidosis Respiratory alkalosis Metabolic alkalosis
Respiratory acidosis Explanation: Respiratory acidosis occurs in conditions that impair alveolar ventilation and cause an increase in plasma PCO2, also know as hypercapnia, along with a decrease in pH. Respiratory acidosis can occur as an acute or chronic disorder but occurs most often as a result of decreased ventilation. Other acid-base imbalances may occur if the respiratory acidosis is not immediately treated.
A client has an increase in her anion gap (AG). What does the nurse determine is the significance of this finding? It indicates the client has metabolic alkalosis. It indicates the client has respiratory alkalosis. It indicates the client has respiratory acidosis. It indicates the client has metabolic acidosis.
Ventricular tachycardia Explanation: When the pH falls to 7.1 to 7.2, cardiac contractility and cardiac output decrease. The heart becomes less responsive to catecholamines and dysrhythmias, including fatal ventricular dysrhythmias, can develop. Ventricular tachycardia is a lethal dysrhythmia that is a priority for the nurse to monitor.
