Assessment Related to Acid-Base Balance
Which should the nurse assess for in all patients who are experiencing an acid-base imbalance?
ABG analysis All patients who are suspected of experiencing an acid-base imbalance will require an ABG analysis. Vital signs All patients who are suspected of experiencing an acid-base imbalance will require a vital signs assessment.
Which nursing actions should the nurse perform when analyzing an ABG during the assessment process for a patient who is suspected of having an acid-base imbalance?
Examining oxygenation status The first step the nurse performs when analyzing an ABG is to examine the oxygenation status to determine if the patient is experiencing hypoxemia. Evaluating the pH The second step the nurse performs when analyzing an ABG is to evaluate the pH to determine if the patient is acidotic or alkalotic. Assessing PaCO2 and HCO3- The third step the nurse performs when analyzing an ABG is to assess PaCO2 and HCO3- values. This allows the nurse to determine whether the underlying issue is metabolic or respiratory in nature. Determining compensation The final step the nurse performs when analyzing an ABG is to determine compensation.
Which assessment finding causes the nurse to suspect that a patient is experiencing metabolic acidosis?
Kussmaul respirations Kussmaul respirations are frequent, deep breaths that constitute a compensatory mechanism in an effort to breathe out more carbon dioxide. This is an assessment finding that would cause the nurse to suspect that the patient is experiencing metabolic acidosis.
The nurse is providing care to a patient with the following ABG values: pH 7.30, PaCO2 40 mm Hg, and HCO3- 20 mEq/L. Which should the nurse document in the medical record regarding this ABG?
Metabolic acidosis Metabolic acidosis is characterized by a decreased pH, a normal PaCO2, and a decreased HCO3-. This is appropriate terminology for the nurse to document in the patient's medical record based on the ABG analysis.
A patient presents with muscle twitching and tetany. Ten minutes after hospital admission, the patient experiences a seizure. Which acid-base imbalance should the nurse suspect?
Metabolic alkalosis Clinical manifestations associated with metabolic alkalosis include muscle twitching and tetany that may progress to seizure.
The nurse is evaluating the ABG results for a patient who is suspected of having an acid-base imbalance. The ABG analysis indicates a decreased pH, an increased PaCO2, and a normal HCO3-. Which conclusion by the nurse is accurate?
Respiratory acidosis A decreased pH, an increased PaCO2, and a normal HCO3- indicate that the patient is experiencing respiratory acidosis.
The nurse is assessing a patient who is diagnosed with respiratory acidosis. Which cardiovascular finding does the nurse anticipate when assessing the cardiovascular system?
Tachycardia Tachycardia is an expected cardiovascular assessment finding for the patient who is experiencing respiratory acidosis. Dysrhythmia Dysrhythmia is an expected cardiovascular assessment finding for the patient who is experiencing respiratory acidosis.
Which clinical manifestation does the nurse anticipate when assessing a patient who is experiencing respiratory alkalosis?
Tachypnea Tachypnea is a clinical manifestation the nurse anticipates for a patient who is experiencing respiratory alkalosis.
