Acid/Base
Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply. 1 Diarrhea 2 Listlessness 3 Weight loss 4 Bradycardia 5 Decreased appetite
1 3 Excessive thyroid hormones increase the metabolic rate, causing an increase in intestinal peristalsis. Excessive thyroid hormones increase the metabolic rate, causing weight loss. Listlessness occurs with hypothyroidism because of a decreased metabolic rate. A slow pulse rate accompanies hypothyroidism, not hyperthyroidism, because of a decreased metabolic rate. Appetite increases (polyphagia) with hyperthyroidism in an effort to meet metabolic needs.
During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism will cause what? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis
1 Metabolic acidosis Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid. Metabolic alkalosis cannot occur with the buildup of lactic acid. Eventually respiratory acidosis can result from decreased respiratory function in late shock, further compounding metabolic acidosis. Respiratory alkalosis may occur as a result of hyperventilation during early shock.
A client is admitted to the hospital after taking an overdose of aspirin. A nasogastric tube is inserted for lavage. Which solution should the nurse obtain for the gastric lavage? 1 Normal saline 2 Lactated Ringer 3 Citrate magnesium 4 Sodium bicarbonate
1 Normal saline A saline solution of 0.9% is considered a physiological or isotonic solution appropriate for gastric lavage because it will not detrimentally influence the client's acid-base balance. Lactated Ringer contains sodium chloride, potassium chloride, and calcium chloride in purified water; it is an intravenous solution. Citrate magnesium affects the lower bowel, not the stomach. Sodium bicarbonate is used to counteract acidosis in some instances of salicylate toxicity, but it is undesirable for lavage because as a systemic alkalinizer, it can precipitate metabolic alkalosis.
A client admitted to the emergency department has ketones in the blood and urine. Which situation associated with this physiologic finding should be the nurse's focus when collecting additional data about this client? 1 Starvation 2 Alcoholism 3 Bone healing 4 Positive nitrogen balance
1 Starvation In starvation there are inadequate carbohydrates available for immediate energy, and stored fats are used in excessive amounts, producing ketones. There is no fat in alcohol; fat oxidation does not occur. Bone healing does not require the use of great amounts of fat; calcium is deposited to form callus. A positive nitrogen balance does not require the use of great amounts of fat.
A client with untreated type 1 diabetes mellitus may lapse into a coma because of acidosis. Which component is increased in the blood and a direct cause of acidosis? 1 Ketones 2 Glucose 3 Lactic acid 4 Glutamic acid
1. Ketones The ketones produced excessively in diabetes are a by-product of the breakdown of body fats and proteins for energy; this occurs when insulin is not secreted or is unable to be used to transport glucose across the cell membrane into the cells. The major ketone, acetoacetic acid, is an alpha-ketoacid that lowers the blood pH, resulting in acidosis. Glucose does not change the pH. Lactic acid is produced as a result of muscle contraction; it is not unique to diabetes. Glutamic acid is a product of protein metabolism.
A client with chronic obstructive pulmonary disease (COPD) reports a 5-pound (2.3 kg) weight gain in one week. What does the nurse recall is the complication that may have precipitated this weight gain? 1 Polycythemia 2 Cor pulmonale 3 Compensated acidosis 4 Left ventricular failure
2 Cor pulmonale A sudden weight gain is an initial sign of right ventricular failure caused by COPD. Polycythemia is associated with polycythemia vera, not COPD. A sudden weight gain is not associated with compensated acidosis. Right, not left, ventricular failure [1] [2] occurs with COPD.
A client appears anxious, exhibiting 40 shallow respirations per minute. The client complains of feeling dizzy and lightheaded and of having tingling sensations of the fingertips and around the lips. What does the nurse conclude that the client's complaints probably are related to? 1 Eupnea 2 Hyperventilation 3 Kussmaul respirations 4 Carbon dioxide intoxication
2 Hyperventilation The client is hyperventilating and blowing off excessive carbon dioxide, which leads to these adaptations; if uninterrupted this can result in respiratory alkalosis. Eupnea is normal, quiet breathing; the client has shallow, rapid breathing. Kussmaul respirations are deep, gasping respirations associated with diabetic acidosis and coma. These adaptations are related to a decreased carbon dioxide level in the body.
Propylthiouracil is prescribed for a client diagnosed with hyperthyroidism. The client asks the nurse, "Why do I have to take this medication if I am going to get radiation therapy?" What explanation does the nurse provide? 1 It binds previously formed thyroid hormones. 2 It decreases production of thyroid hormones. 3 Vascularity of the thyroid gland is decreased. 4 The need for thyroid iodine supplements is reduced
2 It decreases production of thyroid hormones. Propylthiouracil is a thyroid hormone antagonist that inhibits thyroid hormone synthesis by decreasing the use of iodine in the manufacture of these hormones. PTU does not affect the vascularity of the thyroid gland. Iodine-containing agents are given for severe hyperthyroidism and before a thyroidectomy. PTU does not affect the amount of already formed thyroid hormones.
A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect? 1 Hypokalemia 2 Metabolic acidosis 3 Respiratory alkalosis 4 Decreased carbon dioxide level
2 Metabolic acidosis Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.
A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess? 1 Quality of the cry 2 Signs of dehydration 3 Coughing up of feedings 4 Characteristics of the stool
2 Signs of dehydration HPS causes partial and then complete obstruction. Nonprojectile vomiting progresses to projectile vomiting, which rapidly leads to dehydration. The infant's cry is not affected by HPS; pain, except for the pain of hunger, does not appear to be associated with this condition. An infant with a tracheoesophageal fistula, not HPS, is expected to cough up feedings. The characteristics of the stool are not relevant in the assessment of an infant with HPS.
A nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis
3 Respiratory acidosis Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an increased carbon dioxide level leads to respiratory acidosis [1] [2]. Metabolic acidosis occurs with diarrhea; alkaline fluid is lost from the lower gastrointestinal tract. Metabolic alkalosis is caused by excessive loss of hydrogen ions through gastric decompression or excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid.
Surgery to correct hypertrophic pyloric stenosis is performed on a 3-week-old infant who has been fed formula. Which postoperative feeding regimen is most appropriate? 1 Thickened formula 24 hours after surgery 2 Withholding of feedings for the first 24 hours 3 Regular formula feeding within 24 hours of the surgery 4 Additional glucose feedings as desired after the first 24 hours
3. Regular formula feeding within 24 hours of the surgery An initial feeding of glucose and electrolytes in water or breast milk is given 4 to 6 hours after surgery. Once clear fluids are being retained, formula feedings are begun within 24 hours. Thickened formula 24 hours after surgery is not necessary. Regular formula should be started within 24 hours after surgery in an attempt to gradually return the infant to a full feeding schedule. Withholding feedings for the first 24 hours and providing additional glucose feedings as desired after the first 24 hours are not necessary.
After a gastrectomy, a client has a nasogastric tube to low continuous suction. The client begins to hyperventilate. How does the nurse anticipate that this breathing pattern will alter the client's arterial blood gases? 1 Increase the PO 2 level 2 Decrease the pH level 3 Increase the HCO 3 level 4 Decrease the Pco 2 level
4 Decrease the Pco 2 level Hyperventilation results in the increased elimination of carbon dioxide from the blood. The PO 2 level is not affected. The pH level will increase. The carbonic acid level will decrease.
Surgery is performed on a client with a parotid tumor. Postoperative arterial blood gas values are pH 7.32, PCO 2 53 mm Hg, and HCO 3 25 mEq/L (25 mmol/L). Which action should the nurse take? 1 Administer a potent diuretic 2 Obtain a prescription for an alkalinizing agent 3 Have the client breathe into a rebreather bag at a slow rate 4 Encourage the client to cough and then take deep breaths between coughs
4 Encourage the client to cough and then take deep breaths between coughs The client is in respiratory acidosis, probably caused by depressant effects of the anesthetic or a plugged airway; coughing clears the airway, and deep breaths blow off carbon dioxide. Administering a diuretic will not correct respiratory acidosis and may aggravate hypokalemia if present. An alkalinizing agent is not necessary if clearing the airway rectifies the problem. Having the client breathe into a rebreather bag at a slow rate is the treatment for respiratory alkalosis; the client is in respiratory acidosis.
A nurse in the clinic is taking the health history of a 16-year-old. When the nurse asks questions concerning sexual activity, the adolescent begins to perspire and hyperventilate. As her anxiety increases, she indicates that she feels dizzy and short of breath and that her heart is racing. What condition does the nurse identify? 1 Metabolic alkalosis 2 Respiratory acidosis 3 Pulmonary hypertension 4
4 Hyperventilation syndrome Hyperventilation syndrome is respiratory alkalosis that occurs with deep, rapid breathing; the clinical findings are related to an increased pH and lowered bicarbonate and oxygen levels. Metabolic alkalosis is manifested by adaptations such as hypotension, tachycardia, confusion, hyperreflexia, and dysrhythmias. Respiratory acidosis is manifested by adaptations such as tachycardia; headache; altered mental status; muscle twitching; and warm, flushed skin. Pulmonary hypertension occurs when the pulmonary arterial pressure is increased; chronic pulmonary disorders are associated with pulmonary hypertension.
Which would the nurse claim is a cardiovascular manifestation of alkalosis? 1 Anxiety 2 Seizures 3 Hyperreflexia 4 Increased digitalis toxicity
4 Increased digitalis toxicity Increased digitalis toxicity is one of the cardiovascular manifestations of alkalosis. Anxiety and seizures are central nervous system manifestations of alkalosis. Hyperreflexia is a neuromuscular manifestation of alkalosis.
A nurse is caring for a client on mechanical ventilation. The nurse should monitor for which sign of hyperventilation? 1 Tetany 2 Hypercapnia 3 Metabolic acidosis 4 Respiratory alkalosis
4 Respiratory alkalosis Increased rate and depth of breathing result in excessive elimination of CO 2, and respiratory alkalosis [1] [2] can result. Tetany is associated with hypocalcemia. With hyperventilation, CO 2 levels will be decreased (hypocapnia), not elevated. Metabolic acidosis results from excess hydrogen ions caused by a metabolic problem, not a respiratory problem.
A Nitrazine test strip that turns deep blue indicates that the fluid being tested has a pH of what? 1 4.5 2 5.5 3 6.5 4 7.5
4. (7.5) Amniotic fluid changes the color of a Nitrazine strip from yellow to deep blue if the pH of the fluid is 7.5. A pH of 4.5, 5.5, or 6.5 would result in a test strip of yellow, olive yellow, or blue green, respectively.
2. After surgical implantation of radon seeds for oral cancer, what side effects of the radiation does the nurse observe in the client? 1 Nausea or vomiting 2 Hematuria or occult blood 3 Hypotension or bradycardia 4 Abdominal cramping or diarrhea
Nausea or vomiting The mucosa of the mouth and the vomiting center in the brainstem may be affected, producing nausea and vomiting. Hematuria or occult blood and hypotension or bradycardia are not side effects of radiation therapy to the oral cavity. Neither abdominal cramping nor diarrhea is an expected response because of the distance between the radon seeds and the intestines.
A nurse is caring for a client who is experiencing an underproduction of thyroxine (T 4). Which client response is associated with an underproduction of thyroxine? 1 Myxedema 2 Acromegaly 3 Graves disease 4 Cushing disease
Correct 1 Myxedema Myxedema is the severest form of hypothyroidism. Decreased thyroid gland activity means reduced production of thyroid hormones. Acromegaly results from excess growth hormone in adults once the epiphyses are closed. Graves disease results from an excess, not a deficiency, of thyroid hormones. Cushing disease results from excess glucocorticoids. Test-Taking Tip: Eat breakfast or lunch before an exam. Avoid greasy, heavy foods and overeating. This will help keep you calm and give you energy.
A client is admitted to the emergency department after vomiting bright red blood. After the vomiting ceases and the vital signs are stabilized, the client is transferred to a medical-surgical unit. To assess for bleeding, what should the nurse on the medical-surgical unit should monitor the client for? 1 Lethargy 2 Tachycardia 3 Deep breathing 4 Abdominal pain
2 Tachycardia Tachycardia is a cardiovascular compensatory mechanism as the effort to circulate the decreasing blood volume intensifies. Lethargy is not an initial response to blood loss. The client is more apt to be restless; lethargy may occur later. Breathing may be rapid, not deep, with blood loss. Abdominal pain is not a response to blood loss.