Acid/Base Balance Prep U
On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3-, 28 mEq/L. Based on these values, the nurse should prioritize which nursing diagnosis for this client? Deficient fluid volume Metabolic acidosis Ineffective airway clearance Impaired gas exchange
Impaired gas exchange Explanation: The client's below-normal value for the partial pressure of arterial oxygen (PaO2) and an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2) support the nursing diagnosis of Impaired gas exchange. ABG values can't indicate a diagnosis of Ineffective airway clearance (or excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical, not nursing, diagnosis; in any event, these ABG values indicate respiratory, not metabolic, acidosis.
Which of the following may occur with respiratory acidosis? Increased intracranial pressure (ICP) Third spacing Decreased pulse Decreased blood pressure
Increased intracranial pressure (ICP) Explanation: If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis. Respiratory acidosis does not result in the fluid shifts known as third spacing.
A nurse teaches a client experiencing heartburn to take 1.5 oz of aluminum hydroxide when symptoms appear. How many milliliters should the client take? Record your answer using a whole number.
45 Explanation: 1 oz = 30 mL. (1 oz/1.5 oz) = (30 mL/x). x = (1.5 X 30) mL. x = 45 mL.
A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drip is initiated with 50 units of insulin in 100 ml of normal saline solution administered via an infusion pump set at 10 ml/hour. The nurse determines that the client is receiving how many units of insulin each hour? Record your answer using a whole number
5 Explanation: To determine the number of insulin units the client is receiving per hour, the nurse must first determine the number of units in each milliliter of fluid (50 units ÷ 100 ml = 0.5 units/ml). Next, multiply the units per milliliter by the rate of milliliters per hour (0.5 units × 10 ml/hr = 5 units).
A client with emphysema is at a greater risk for developing what acid-base imbalance? Chronic metabolic acidosis Metabolic alkalosis Respiratory alkalosis Chronic respiratory acidosis
Chronic respiratory acidosis Explanation: Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis
The nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? Metabolic alkalosis Respiratory acidosis Metabolic acidosis Hypercalcemia
Metabolic alkalosis Explanation: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? pH Partial pressure of arterial carbon dioxide (PaCO2) Partial pressure of arterial oxygen (PaO2) Bicarbonate (HCO3-)
Partial pressure of arterial oxygen (PaO2) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2
A client's arterial blood gas analysis reveals an excess of carbon dioxide. The nurse should recognize that this is consistent with which of the following? Metabolic acidosis Respiratory acidosis Respiratory alkalosis Metabolic alkalosis
Respiratory acidosis Explanation: An increased level of dissolved carbon dioxide (PaCO2) indicates respiratory acidosis. Metabolic acidosis and alkalosis are not correct because this is a respiratory issue, not a metabolic one. Respiratory alkalosis would have a PaCO2 deficit, not an increase.
A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance? Returning acid to the body's circulation Sequestering free hydrogen ions in the nephrons Returning bicarbonate to the body's circulation Excreting bicarbonate in the urine
Returning bicarbonate to the body's circulation Explanation: The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions.
A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance? Returning bicarbonate to the body's circulation Sequestering free hydrogen ions in the nephrons Excreting bicarbonate in the urine Returning acid to the body's circulation
Returning bicarbonate to the body's circulation Explanation: The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions.
The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The decrease in pH exists because the client's lungs: are not able to blow off carbon dioxide. are unable to inspire sufficient oxygen. have ineffective cilia from years of smoking. are unable to exchange oxygen and carbon dioxide.
are not able to blow off carbon dioxide. Explanation: In clients with chronic respiratory acidosis, the client is unable to blow off carbon dioxide leaving in increased amount of hydrogen in the system. The increase in hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas exchange can occur, but the lungs' ability to remove carbon dioxide from the system is compromised. Although individuals with COPD frequently have a history of smoking, impaired ciliary function is not the cause of the acidosis.
A nurse preceptor is working with a student nurse who is administering medications. Which statement by the student indicates an understanding of the action of an antacid? "The action occurs in the large intestine by increasing electrolyte absorption into the system that decreases pepsin absorption." "The action occurs in the esophagus by increasing peristalsis and improving movement of food into the stomach." "The action occurs in the small intestine, where the drug coats the lining and prevents further ulceration." "The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity."
"The action occurs in the stomach by increasing the pH of the stomach contents and decreasing pepsin activity." Explanation: The action of an antacid occurs in the stomach. The anions of an antacid combine with the acidic hydrogen cations secreted by the stomach to form water, thereby increasing the pH of the stomach contents. Increasing the pH and decreasing the pepsin activity provide symptomatic relief from peptic ulcer disease. Antacids don't work in the large or small intestine or in the esophagus.
A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg? Record your answer using a whole number.
80 Explanation: To obtain the MAP, use this formula: MAP = [systolic BP + (2 X diastolic BP)]/3 MAP = [120 + (2 X 60)]/3 MAP = 240/3 = 80.
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? Administer oxygen by nasal cannula as ordered. Instruct the client to breathe into a paper bag. Auscultate breath sounds bilaterally every 4 hours. Encourage the client to deep-breathe and cough every 2 hours.
Administer oxygen by nasal cannula as ordered. Explanation: When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client reinhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.
The nurse is concerned about the risks of hypoxemia and metabolic acidosis in a client who is in shock. What finding should the analyze for evidence of hypoxemia and metabolic acidosis in a client with shock? Red blood cells (RBCs) and hemoglobin count findings White blood cell differential Arterial blood gas (ABG) findings Oxygen saturation level
Arterial blood gas (ABG) findings Explanation: Analysis of ABG findings is essential for evidence of hypoxemia and metabolic acidosis. Low RBCs and hemoglobin correlate with hypovolemic shock and can lead to poor oxygenation. An elevated white blood cell count supports septic shock. Oxygen saturation levels are usually affected by hypoxemia but cannot be used to diagnose acid-base imbalances such as metabolic acidosis.
A client is diagnosed with diabetic ketoacidosis. Which of the following findings would the nurse anticipate? Potassium 4.5 mEq/L Platelets 309 Fasting blood glucose 70 mg/dL (3.89 mmol/L) Arterial pH 7.33
Arterial pH 7.33 Explanation: In diabetic ketoacidosis, the client is acidic with a pH below 7.35. The potassium level is typically low. The client is hyperglycemic. Potassium level may be high or low depending upon renal function and potassium replacement. Also, blood blood glucose will be elevated. Platelet count should be within normal limits.
A client with emphysema is at a greater risk for developing what acid-base imbalance? Chronic respiratory acidosis Chronic metabolic acidosis Respiratory alkalosis Metabolic alkalosis
Chronic respiratory acidosis Explanation: Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.
A client with emphysema is at a greater risk for developing what acid-base imbalance? Respiratory alkalosis Chronic respiratory acidosis Metabolic alkalosis Chronic metabolic acidosis
Chronic respiratory acidosis Explanation: Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.
A nurse is assessing a 6-month-old infant at a well-baby check. The parent says that the infant has been having diarrhea for the last 2 days. Which of the following is the nurse's priority action? Collect more data from parent about the diarrhea Complete designated teaching for the 6-month visit Notify the healthcare provider Instruct mother to bring the infant to the emergency department
Collect more data from parent about the diarrhea Explanation: The nurse should obtain a more detailed history and assessment on the infant to determine the next steps in care. Routine teaching, use of the emergency department, or notifying the primary healthcare provider is not a priority until the diarrhea is evaluated.
The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. Suction the client's airway. Document presenting signs and symptoms. Administer IV bicarbonate. Maintain intake and output records. Compare ABG findings with previous results.
Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms.
The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. Administer IV bicarbonate. Compare ABG findings with previous results. Document presenting signs and symptoms. Maintain intake and output records. Suction the client's airway.
Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Explanation: Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The result is retention of sodium bicarbonate and increased base bicarbonate. Nursing management includes documenting all presenting signs and symptoms to provide accurate baseline data, monitoring laboratory values, comparing ABG findings with previous results (if any), maintaining accurate intake and output records to monitor fluid status, and implementing prescribed medical therapy.
A client has been admitted to the hospital for the treatment of diabetic ketoacidosis, a problem that was accompanied by a random blood glucose reading of 31.9 mmol/L (575 mg/dL), vomiting, and shortness of breath. This client has experienced which of the following phenomena? Infection Morbidity Exacerbation Risk factor
Exacerbation Explanation: This client has experienced a significant exacerbation of his chronic disease (diabetes mellitus), which has manifested as an acute threat to his health. Morbidity is an epidemiological statistic of the frequency of a disease. His problem does not have an infectious etiology and while risk factors underlie his present condition, they are not the essence of his current state.
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? Myasthenia gravis Extreme anxiety Type 1 diabetes mellitus Opioid overdose
Extreme anxiety Explanation: Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.
Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? Opioid overdose Myasthenia gravis Extreme anxiety Type 1 diabetes mellitus
Extreme anxiety Explanation: Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.
On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3-, 28 mEq/L. Based on these values, the nurse should prioritize which nursing diagnosis for this client? Ineffective airway clearance Deficient fluid volume Metabolic acidosis Impaired gas exchange
Impaired gas exchange Explanation: The client's below-normal value for the partial pressure of arterial oxygen (PaO2) and an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2) support the nursing diagnosis of Impaired gas exchange. ABG values can't indicate a diagnosis of Ineffective airway clearance (or excess) or Risk for deficient fluid volume. Metabolic acidosis is a medical, not nursing, diagnosis; in any event, these ABG values indicate respiratory, not metabolic, acidosis.
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? Administer ordered supplemental oxygen. Offer the client fluids frequently. Administer an ordered decongestant. Instruct the client to breathe into a paper bag.
Instruct the client to breathe into a paper bag. Explanation: The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.
A client is in a metabolic acidosis from severe diarrhea. What assessment finding would be most concerning? Irregular heart rate Abdominal cramping Respiratory rate of 28 Excoriated skin around the rectum
Irregular heart rate Explanation: Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates, leading to metabolic acidosis. The diarrhea would result in skin breakdown. Abdominal cramping would be anticipated. Kussmaul respirations are anticipated as a compensatory response. Irregular heart rate could be a sign of electrolyte imbalances and is most concerning.
A client is in a metabolic acidosis from severe diarrhea. What assessment finding would be most concerning? Respiratory rate of 28 Excoriated skin around the rectum Abdominal cramping Irregular heart rate
Irregular heart rate Explanation: Diarrhea causes a bicarbonate deficit. With loss of the relative alkalinity of the lower GI tract, the relative acidity of the upper GI tract predominates, leading to metabolic acidosis. The diarrhea would result in skin breakdown. Abdominal cramping would be anticipated. Kussmaul respirations are anticipated as a compensatory response. Irregular heart rate could be a sign of electrolyte imbalances and is most concerning.
The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include: high blood pressure. Kussmaul's respirations. dry, flaky skin. excessive hunger.
Kussmaul's respirations. Explanation: The client with diabetic ketoacidosis exhibits Kussmaul's respiration, as well as flushed skin, dry mouth, urinary frequency, hyperglycemia, and ketonuria. Excessive hunger and high blood pressure are not associated with diabetic ketoacidosis.
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Light-headedness or paresthesia Hallucinations or tinnitus Nausea or vomiting Abdominal pain or diarrhea
Light-headedness or paresthesia Explanation: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Nausea or vomiting Hallucinations or tinnitus Abdominal pain or diarrhea Light-headedness or paresthesia
Light-headedness or paresthesia Explanation: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? Metabolic alkalosis Respiratory acidosis Respiratory alkalosis Metabolic acidosis
Metabolic acidosis Explanation: The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate).
A nurse reviews the arterial blood gas (ABG) values of a client with complaints of difficulty breathing: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What assessment finding would the nurse anticipate based on these blood gases? Nausea and vomiting Complaints of constipation Tachypnea Bradypnea
Metabolic acidosis. Explanation: This client has metabolic acidosis, which typically manifests with a low pH, low bicarbonate level, normal to low PaCO2, and normal PaO2. The client's serum electrolyte levels also support metabolic acidosis, which include an elevated potassium level, normal to elevated chloride level, and normal calcium level. The client's anion gap of 30 mEq/L is high, also indicative of metabolic acidosis. This kind of metabolic acidosis occurs with diabetic ketoacidosis and other disorders.
An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder? Hypoglycemia Metabolic alkalosis Hyperkalemia Metabolic acidosis
Metabolic alkalosis Explanation: In a client with bulimia nervosa, metabolic alkalosis may occur secondary to hydrogen loss caused by frequent, self-induced vomiting. Typically, the blood glucose level is within normal limits, making hypoglycemia unlikely. In bulimia nervosa, hypokalemia is more common than hyperkalemia and typically results from potassium loss related to frequent vomiting.
An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder? Metabolic acidosis Hypoglycemia Hyperkalemia Metabolic alkalosis
Metabolic alkalosis Explanation: In a client with bulimia nervosa, metabolic alkalosis may occur secondary to hydrogen loss caused by frequent, self-induced vomiting. Typically, the blood glucose level is within normal limits, making hypoglycemia unlikely. In bulimia nervosa, hypokalemia is more common than hyperkalemia and typically results from potassium loss related to frequent vomiting.
An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder? Metabolic alkalosis Metabolic acidosis Hyperkalemia Hypoglycemia
Metabolic alkalosis Explanation: In a client with bulimia nervosa, metabolic alkalosis may occur secondary to hydrogen loss caused by frequent, self-induced vomiting. Typically, the blood glucose level is within normal limits, making hypoglycemia unlikely. In bulimia nervosa, hypokalemia is more common than hyperkalemia and typically results from potassium loss related to frequent vomiting.
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? Metabolic acidosis Metabolic alkalosis Respiratory alkalosis Respiratory acidosis
Metabolic alkalosis Explanation: Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma biacarbonate concentration. The most common cuase of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and choloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.
A 75-year-old client who complains of a "sour stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for what acid-base imbalance? Respiratory alkalosis Metabolic acidosis Respiratory acidosis Metabolic alkalosis
Metabolic alkalosis Explanation: Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The client's regular use of baking soda (sodium bicarbonate) may place him at risk for this condition. Metabolic acidosis refers to decreased plasma pH because of increased organic acids (acids other than carbonic acid) or decreased bicarbonate. Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary with expired air.
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic alkalosis Explanation: Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary.
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis
Metabolic alkalosis Explanation: Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary.
the nurse is caring for a client admitted with pyloric stenosis. A nasogastric tube placed upon admission is on low intermittent suction. Upon review of the morning's blood work, the nurse observes that the patient's potassium is below reference range. The nurse should recognize that the patient may be at risk for what imbalance? Respiratory acidosis Hypercalcemia Metabolic alkalosis Metabolic acidosis
Metabolic alkalosis Explanation: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This client would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory status.
A client has vomited several times over the past 12 hours. The nurse should recognize the risk of what complication? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis
Metabolic alkalosis Explanation: Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.
A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? Metabolic acidosis and hypokalemia Metabolic acidosis and hyperkalemia Metabolic alkalosis and hyperkalemia Metabolic alkalosis and hypokalemia
Metabolic alkalosis and hypokalemia Explanation: Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive vomiting causes loss of these substances, which can lead to metabolic alkalosis and hypokalemia. Excessive vomiting doesn't cause metabolic acidosis or hyperkalemia.
A client presents to the emergency department, reporting that he has been vomiting every 30 to 40 minutes for the past 8 hours. Frequent vomiting puts this client at risk for which imbalances? Metabolic acidosis and hypokalemia Metabolic alkalosis and hypokalemia Metabolic alkalosis and hyperkalemia Metabolic acidosis and hyperkalemia
Metabolic alkalosis and hypokalemia Explanation: Gastric acid contains large amounts of potassium, chloride, and hydrogen ions. Excessive vomiting causes loss of these substances, which can lead to metabolic alkalosis and hypokalemia. Excessive vomiting doesn't cause metabolic acidosis or hyperkalemia.
A hospitalized adolescent with type 1 diabetes mellitus is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client's breath. The client uses insulin lispro. The last meal was lunch, 2 hours ago. Place the nursing actions in the order in which the nurse should perform them. All options must be used. 1 Start an IV infusion with normal saline solution. 2 Administer insulin lispro. 3 Obtain a fingerstick test for blood glucose. 4 Notify the health care provider (HCP). SUBMIT ANSWER
Obtain a fingerstick test for blood glucose. Notify the health care provider (HCP). Start an IV infusion with normal saline solution. Administer insulin lispro.
Water movement from the side of the membrane having a lesser number of particles and greater concentration of water to the side having a greater number of particles and lesser concentration of water is termed:
Osmosis
A client has meconium-stained amniotic fluid. Fetal scalp sampling indicates a blood pH of 7.12; fetal bradycardia is present. Based on these findings, the nurse should take which action? Administer amnioinfusion. Reposition the client. Prepare for cesarean birth. Start I.V. oxytocin infusion as ordered.
Prepare for cesarean birth. Explanation: Fetal blood pH of 7.19 or lower signals severe fetal acidosis; meconium-stained amniotic fluid and bradycardia are further signs of fetal distress that warrant cesarean birth. Amnioinfusion is indicated when the only abnormal fetal finding is meconium-stained amniotic fluid. Client repositioning may improve uteroplacental perfusion, but only serve as a temporary measure because the risk of fetal asphyxia is imminent. Oxytocin administration increases contractions, exacerbating fetal stress.
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare for gastric lavage. Obtain a urine specimen for drug screening. Prepare to assist with ventilation. Monitor the client's heart rhythm.
Prepare to assist with ventilation. Explanation: Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.7 kPa); HCO3-, 24 mEq/L (24 mmol/l). The nurse determines that which of the following is a possible cause for these findings? Chronic obstructive pulmonary disease (COPD). Diabetic ketoacidosis with Kussmaul's respirations. Myocardial infarction. Pulmonary embolus.
Pulmonary embolus. Explanation: A PaCO2 of 28 mm Hg (3.7 kPa) and PaO2 of 50 mm Hg (6.7 kPa) are both abnormal; the PaO2 of 50 mm Hg (6.7 kPa) signifies acute respiratory failure. In evaluating possible causes for this disorder, the nurse should consider conditions that lead to hypoxia and hyperventilation, such as pulmonary embolus. COPD is typically associated with respiratory acidosis and elevated PaCO2. The client with diabetic ketoacidosis most often has metabolic acidosis. A myocardial infarction does not often cause an acid-base imbalance because the primary problem is cardiac in origin.
As status asthmaticus worsens, the nurse would expect the client to experience which acid-base imbalance?
Respiratory acidosis Explanation: As status asthmaticus worsens, the PaCO increases and the pH decreases, reflecting respiratory acidosis.
As status asthmaticus worsens, the nurse would expect the client to experience which acid-base imbalance? Metabolic alkalosis Respiratory acidosis Respiratory alkalosis Metabolic acidosis
Respiratory acidosis Explanation: As status asthmaticus worsens, the PaCO increases and the pH decreases, reflecting respiratory acidosis.
In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to what acid-base imbalance? Metabolic acidosis Respiratory acidosis Respiratory alkalosis Metabolic alkalosis
Respiratory acidosis Explanation: Increased carbon dioxide tension in arterial blood leads to respiratory acidosis and chronic respiratory failure. In acute illness, worsening hypercapnia can lead to acute respiratory failure. The other acid-base imbalances would not correlate with COPD.
A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? Respiratory acidosis Metabolic alkalosis Respiratory alkalosis Metabolic acidosis
Respiratory acidosis Explanation: Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.
A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? Respiratory alkalosis Metabolic alkalosis Metabolic acidosis Respiratory acidosis
Respiratory acidosis Explanation: Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.
The nurse is caring for a client with chronic obstructive pulmonary disease. The client reports that he is having difficulty breathing and is feeling fatigued. The nurse realizes that this client is at high risk for which condition? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis Explanation: Respiratory acidosis occurs when the body is unable to blow off CO2 due to the hypoventilation of disease processes such as COPD. An increase in blood carbon dioxide concentration occurs and a decreased pH causing acidosis. Respiratory alkalosis is a decrease in acidity of the blood and often caused by hyperventilation. Metabolic acidosis and alkalosis are not directly caused by respiratory disorders.
A client has been hospitalized with myxedema coma. What acid-base imbalance would be expected in this client? Metabolic acidosis Respiratory acidosis Respiratory alkalosis Respiratory alkalosis
Respiratory acidosis Explanation: The client's respiratory drive is depressed, resulting in alveolar hypoventilation, progressive carbon dioxide retention, narcosis, and coma. These symptoms, along with cardiovascular collapse and shock, require aggressive and intensive therapy if the client is to survive.
A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance? Returning bicarbonate to the body's circulation Excreting bicarbonate in the urine Sequestering free hydrogen ions in the nephrons Returning acid to the body's circulation
Returning bicarbonate to the body's circulation Explanation: The kidney performs two major functions to assist in acid-base balance. The first is to reabsorb and return to the body's circulation any bicarbonate from the urinary filtrate; the second is to excrete acid in the urine. Retaining bicarbonate will counteract an acidotic state. The nephrons do not sequester free hydrogen ions.
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3-, 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which conclusion would be accurate? The client's PaO2 level is within normal range. `The client is severely hypoxic. The oxygen level is low but poses no risk for the client. The client requires oxygen therapy with very low oxygen concentrations.
The client is severely hypoxic. Explanation: Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When the PaO2 value falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg or more (7.3 to 8 kPa).
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3-, 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which conclusion would be accurate? `The client is severely hypoxic. The client requires oxygen therapy with very low oxygen concentrations. The oxygen level is low but poses no risk for the client. The client's PaO2 level is within normal range.
The client is severely hypoxic. Explanation: Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When the PaO2 value falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg or more (7.3 to 8 kPa).
Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration? The cells in the alveoli are so damaged by the client's long history of respiratory problems that increased oxygen levels and reduced carbon dioxide levels likely will cause the cells to burst. The oxygen will be lost at the client's nostrils if given at a higher level with a nasal cannula. The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. The client's long history of respiratory problems indicates that he would be unable to absorb oxygen given at a higher rate.
The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. Explanation: Relatively low concentrations of oxygen are administered to clients with COPD so as not to eliminate their respiratory drive. Carbon dioxide content in the blood normally regulates respirations. Clients with COPD, though, are often accustomed to high carbon dioxide levels; the low oxygen blood level is their stimulus to breathe. If they receive excessive oxygen and experience a drop in the blood carbon dioxide level, they may stop breathing. Oxygen flow rate is not diminished at high levels when administered through a nasal cannula. The client's ability to absorb oxygen administered at a higher level is not affected. Increased oxygen levels and decreased carbon dioxide levels cannot cause cells to burst.
The body of a critically ill client may use which of the following mechanisms to maintain normal pH? The lungs eliminate carbonic acid by blowing off more CO2. The kidneys retain more HCO3 to raise the pH. The lungs increase tidal volume. The lungs retain more CO2 to lower the pH.
The lungs eliminate carbonic acid by blowing off more CO2. Explanation: To maintain normal pH in critically ill clients, the lungs eliminate carbonic acid by blowing off more CO2. To maintain normal pH in critically ill clients, the lungs conserve CO2 by slowing respiratory volume. This is the way the body would compensate during an acid-base imbalance in cases of metabolic alkalosis. This is the way the body would compensate during an acid-base imbalance in cases of metabolic acidosis.
A nurse working in the emergency department (ED) reviews arterial blood gas (ABG) values for a client diagnosed with heatstroke. Blood gas values are pH 7.48, pCO2 34, pO2 95, CO2 23, HCO3 22, and SO2 98%. What nursing interventions demonstrate the nurse's understanding of the patient's ABG's and knowledge of Maslow's hierarchy of needs when providing care for this patient? The nurse prepares for endotracheal intubation and mechanical ventilation for the client Lab values are within normal limits and contacts the client's family to be with the patient while in the ED The nurse immediately starts an intravenous line (IV) of dextrose 50% in a water solution (D50W) The nurse completes a spiritual assessment and provides appropriate clergy support for the client
The nurse prepares for endotracheal intubation and mechanical ventilation for the client Explanation: This client is experiencing respiratory alkalosis related to heatstroke. The pH level is elevated in hyperventilation; the client's hyperventilation will "blow off" more CO2, leading to lower pCO2 levels. Decreased pCO2 is caused by hyperventilation. Decreased CO2 levels are seen in renal failure. Renal failure is a sign of heatstroke. With rapid breathing SO2 can be increased with deep or rapid breathing. Acute airway management is indicated to improve tissue oxygenation. Airway support meets the client's physiologic need for a clear airway. Spiritual support is a higher level (self-actualization) on Maslow's hierarchy. Providing IV management for circulatory support is a basic physiologic need; however, airway management is priority.
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? Absence of protein Specific gravity of 1.03 Absence of glucose Urine pH of 3.0
Urine pH of 3.0 Explanation: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.002 to 1.035, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? Specific gravity of 1.03 Absence of protein Urine pH of 3.0 Absence of glucose
Urine pH of 3.0 Explanation: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.002 to 1.035, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.
The student nurse asks why a client is receiving an IV of lactated Ringer's with potassium following an episode of diabetic ketoacidosis. What is the best response by the nurse? In acidosis, the sodium moves into the cells to buffer the acid and displaces the potassium. The lactated Ringer's helps restore the alkaline pH. Lactated Ringer's will help lower the blood pH when hypokalemia is related to ketoacidosis. Hypokalemia is associated with uncontrolled diabetes, and the lactated Ringer's is isotonic fluid replacement. With acidosis, the intracellular potassium switches places with the plasma hydrogen ions to buffer the acidosis; the lactated Ringer's helps restore the bicarbonate reserves.
With acidosis, the intracellular potassium switches places with the plasma hydrogen ions to buffer the acidosis; the lactated Ringer's helps restore the bicarbonate reserves. Explanation: In diabetic ketoacidosis, the cellular buffers will be activated. Potassium will move out of the cell and hydrogen will move inside the cells to lessen the impact on the plasma pH. Once the acidosis is corrected by bicarbonate injections and IV lactated Ringer's, potassium will move back into the cells, resulting in hypokalemia. Potassium levels will be monitored closely, and replacement will be initiated. Lactated Ringer's helps increase the blood pH and provides a source of bicarbonate replacement to replenish the base portion of the 1:20 acid-to-base relationship that helps maintain the blood at the pH of 7.35 to 7.45. Sodium does not switch with potassium in an acidotic state.
The student nurse asks why a client is receiving an IV of lactated Ringer's with potassium following an episode of diabetic ketoacidosis. What is the best response by the nurse? In acidosis, the sodium moves into the cells to buffer the acid and displaces the potassium. The lactated Ringer's helps restore the alkaline pH. Lactated Ringer's will help lower the blood pH when hypokalemia is related to ketoacidosis. With acidosis, the intracellular potassium switches places with the plasma hydrogen ions to buffer the acidosis; the lactated Ringer's helps restore the bicarbonate reserves. Hypokalemia is associated with uncontrolled diabetes, and the lactated Ringer's is isotonic fluid replacement.
With acidosis, the intracellular potassium switches places with the plasma hydrogen ions to buffer the acidosis; the lactated Ringer's helps restore the bicarbonate reserves. Explanation: In diabetic ketoacidosis, the cellular buffers will be activated. Potassium will move out of the cell and hydrogen will move inside the cells to lessen the impact on the plasma pH. Once the acidosis is corrected by bicarbonate injections and IV lactated Ringer's, potassium will move back into the cells, resulting in hypokalemia. Potassium levels will be monitored closely, and replacement will be initiated. Lactated Ringer's helps increase the blood pH and provides a source of bicarbonate replacement to replenish the base portion of the 1:20 acid-to-base relationship that helps maintain the blood at the pH of 7.35 to 7.45. Sodium does not switch with potassium in an acidotic state.
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3-, 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which conclusion would be accurate? The oxygen level is low but poses no risk for the client. The client's PaO2 level is within normal range. The client requires oxygen therapy with very low oxygen concentrations. `The client is severely hypoxic.
`The client is severely hypoxic. Explanation: Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When the PaO2 value falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg or more (7.3 to 8 kPa).
The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first: start an intravenous infusion. administer oxygen. institute rewarming. prepare for intubation.
administer oxygen. Explanation: Near-drowning victims typically suffer hypoxia and mixed acidosis. The priority is to restore oxygenation and prevent further hypoxia. Here, the client has blunted sensorium, but is not unconscious; therefore, delivery of supplemental oxygen with a mask is appropriate. Warming protocols and fluid resuscitation will most likely be needed to help correct acidosis, but these interventions are secondary to oxygen administration. Intubation is required if the child is comatose, shows signs of airway compromise, or does not respond adequately to more conservative therapies.
A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3 26 (26 mmol/L). Which prescriptions should the nurse implement first? albuterol nebulizer chest x-ray ipratropium inhaler sputum culture
albuterol nebulizer Explanation: The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable.
A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3 26 (26 mmol/L). Which prescriptions should the nurse implement first? sputum culture ipratropium inhaler chest x-ray albuterol nebulizer
albuterol nebulizer Explanation: The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable.
The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The decrease in pH exists because the client's lungs: have ineffective cilia from years of smoking. are unable to inspire sufficient oxygen. are unable to exchange oxygen and carbon dioxide. are not able to blow off carbon dioxide.
are not able to blow off carbon dioxide. Explanation: In clients with chronic respiratory acidosis, the client is unable to blow off carbon dioxide leaving in increased amount of hydrogen in the system. The increase in hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas exchange can occur, but the lungs' ability to remove carbon dioxide from the system is compromised. Although individuals with COPD frequently have a history of smoking, impaired ciliary function is not the cause of the acidosis.
The nurse is assessing a child with ketoacidosis. The nurse should particularly observe if the client has: elevated blood pressure. slow, bounding pulse rate. deep, rapid respirations. diaphoretic, warm skin.
deep, rapid respirations. Explanation: The accumulation of ketones, organic acids that readily release free hydrogen ions causing blood pH to fall, leads to ketoacidosis. To compensate, the respiratory buffering system is activated, which results in the child taking deep, rapid breaths to rid the body of excess carbon dioxide. This characteristic breathing pattern is known as Kussmaul's respirations.
The nurse is assessing a child with ketoacidosis. The nurse should particularly observe if the client has: diaphoretic, warm skin. slow, bounding pulse rate. deep, rapid respirations. elevated blood pressure.
deep, rapid respirations. Explanation: The accumulation of ketones, organic acids that readily release free hydrogen ions causing blood pH to fall, leads to ketoacidosis. To compensate, the respiratory buffering system is activated, which results in the child taking deep, rapid breaths to rid the body of excess carbon dioxide. This characteristic breathing pattern is known as Kussmaul's respirations. Typically with ketoacidosis, the pulse rate would be more rapid and weak due to dehydration and loss of electrolytes. Typically with ketoacidosis, the skin would be dry due to dehydration. With ketoacidosis, hypotension results from the contracted blood volume secondary to dehydration.
Which physical sensation will the client who has had an abdominal hysterectomy most likely experience if she hyperventilates while performing deep-breathing exercises? dyspnea dizziness blurred vision mental confusion
dizziness Explanation: Hyperventilation occurs when the client breathes so rapidly and deeply that she exhales excessive amounts of carbon dioxide. A characteristic symptom of hyperventilation is dizziness. To avoid hyperventilation, the nurse should assist the client in the practice of slow, deep breathing in a regular breathing pattern. Dyspnea, blurred vision, and mental confusion are not associated with hyperventilation.
The nurse observes a client with a history of panic attacks is hyperventilating. The nurse should: tell the client to take several deep, slow breaths and exhale normally. give the client a low concentration of oxygen by nasal cannula. instruct the client to put his head between his knees. have the client breathe into a paper bag.
have the client breathe into a paper bag. Explanation: The best way to ease symptoms caused by hyperventilation is to have the client breathe into a paper bag. This helps to raise carbon dioxide level, which encourages deeper, slower breathing. The symptoms of hyperventilation will not be alleviated by having the client put his head between his knees, giving the client low concentrations of oxygen, or having the client take deep, slow breaths and exhaling normally.
The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? hypoxia not responsive to oxygen therapy metabolic acidosis severe, unexplained electrolyte imbalance elevated carbon dioxide level
hypoxia not responsive to oxygen therapy Explanation: A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.
The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? metabolic acidosis elevated carbon dioxide level severe, unexplained electrolyte imbalance hypoxia not responsive to oxygen therapy
hypoxia not responsive to oxygen therapy Explanation: A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.
The nurse is admitting a toddler with the diagnosis of near-drowning in a neighbor's heated swimming pool to the emergency department. The nurse should assess the child for: hypoxia. cutaneous capillary paralysis. hypothermia. fluid aspiration.
hypoxia. Explanation: Hypoxia is the primary problem because it results in brain cell damage. Irreversible brain damage occurs after 4 to 6 minutes of submersion. Hypothermia occurs rapidly in infants and children because of their large body surface area. Hypothermia is more of a problem when the child is in cold water. Although fluid aspiration occurs in most drownings and results in atelectasis and pulmonary edema, further aggravating hypoxia, hypoxia is the primary problem. Cutaneous capillary paralysis is not a problem.
On admission, the client's arterial blood gas (ABG) values were: pH, 7.20; PaO2, 64 mm Hg (8.5 kPa); PaCO2, 60 mm Hg (8 kPa); and HCO3-, 22 mEq/L (22 mmol/L). A chest tube is inserted, and oxygen at 4 L/minute is started. Thirty minutes later, repeat blood gas values are: pH, 7.30; PaO2, 76 mm Hg (10.1 kPa); PaCO2, 50 mm Hg (6.7 kPa); and HCO3-, 22 mEq/L (22 mmol/L). This change would indicate: impending respiratory failure. obstruction in the chest tubes. improving respiratory status. developing respiratory alkalosis.
improving respiratory status. Explanation: The ABG values after chest tube insertion are returning to normal, indicating that treatment is effective. Impending respiratory failure would be indicated by a decreasing PaO2 or an increasing PaCO2. The client is not alkalotic because the pH values are below 7.35. If the chest tubes were obstructed, the client's respiratory status would deteriorate.
The nurse is caring for a client with multiple organ failure who is in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? Pancreas and heart Kidneys and liver Lungs and kidneys Heart and lungs
lungs and kidneys
The nurse should assess the client with severe diarrhea for which acid-base imbalance? metabolic alkalosis respiratory acidosis respiratory alkalosis metabolic acidosis
metabolic acidosis Explanation: A client with severe diarrhea loses large amounts of bicarbonate, resulting in metabolic acidosis. Metabolic alkalosis does not result in this situation. Diarrhea does not affect the respiratory system.
A client is admitted to the psychiatric clinic for treatment of anorexia nervosa. At the beginning of the client's hospitalization, the most important nursing action is to: instruct the client to keep an accurate record of her food and fluid intake. monitor the client's vital signs, serum electrolyte levels, and acid-base balance. weigh the client daily, after the evening meal. severely restrict the client's physical activities.
monitor the client's vital signs, serum electrolyte levels, and acid-base balance. Explanation: An anorexic client who requires hospitalization is in poor physical condition as a result of starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and acid-base balance is crucial. Restricting the client's physical activities may worsen anxiety. A weight obtained after breakfast is more accurate than one obtained after the evening meal. Instructing the client to keep a record of food and fluid intake would reward the client with attention for not eating and would reinforce the control issues that are central to the underlying psychological problem; also, the client might record food and fluid intake inaccurately.
A primigravid client at 38 weeks' gestation comes to the labor room because "my water broke." The health care provider (HCP) asks the nurse to verify spontaneous rupture of membranes using nitrazine paper. The nurse observes that the nitrazine paper turns bright blue. The nurse's next action should be to: document the findings of the nitrazine test. offer the client a sterile sanitary pad after performing perineal care. perform a sterile vaginal examination to assess the cervix. notify the HCP that the membranes are ruptured.
notify the HCP that the membranes are ruptured. Explanation: Nitrazine paper responds to alkaline fluids by changing blue; amniotic fluid is alkaline so the color verifies that the membranes are ruptured. The nurse notifies the provider that membranes are ruptured so that a plan of action can be developed. Rupture of membranes in the absence of labor increases the risk of infection. Vaginal examinations are limited until labor is initiated. Wearing a sanitary pad increases potential for infection. Documentation of the Nitrazine test is completed after notifying the provider.
A nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the client's blood? pH PaO2 PaCO2 HCO3-
pH Explanation: The pH value in an ABG report reflects the acid concentration in the blood. The partial pressure of arterial oxygen (PaO2) value indicates the amount of oxygen dissolved in the blood; the partial pressure of arterial carbon dioxide (PaCO2) value represents the amount of carbon dioxide dissolved in the blood. The bicarbonate (HCO3-) value indicates the amount of bicarbonate, or base, in the blood.
To confirm an acid-base imbalance, it is necessary to assess which findings from the results of a client's arterial blood gas (ABG) results? Select all that apply. HCO3 pH Na+ K+ PaCO2 Nitrogen
pH PaCO2 HCO3 Explanation: Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate (HCO3). The two types of acid-base imbalances are acidosis and alkalosis.
The nurse is caring for a client with end-stage kidney disease. What arterial blood gas results are most closely associated with this disorder? pH 7.50, PaCO2 29, HCO3 22- pH 7.31, PaCO2 48, HCO3 24- pH 7.47, PaCO2 45, HCO3 33- pH 7.20, PaCO2 36, HCO3 14-
pH 7.20, PaCO2 36, HCO3 14- Explanation: Metabolic acidosis occurs in ESKD because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH3-) and to reabsorb sodium bicarbonate (HCO3-). There is also decreased excretion of phosphates and other organic acids.
Arterial blood gas analysis would reveal which of the following related to acute respiratory failure? PaO2 80 mm Hg pH 7.24 PaCO2 32 mm Hg pH 7.35
pH 7.24 Explanation: Acute respiratory failure (ARF) is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with a decreased arterial pH.Arterial blood gas analysis would reveal which of the following related to acute respiratory failure? PaO2 80 mm Hg pH 7.24 PaCO2 32 mm Hg pH 7.35
A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which of the following results are consistent with this disorder? pH 7.46, PaO2 80 mm Hg pH 7.36, PaCO2 32 mm Hg pH 7.28, PaO2 50 mm Hg pH 7.35, PaCO2 48 mm Hg
pH 7.28, PaO2 50 mm Hg Explanation: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.
When evaluating a client's arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? HCO3 21 mEq/L PaCO2 36 pH 7.48 O2 saturation 95%
pH 7.48 Explanation: Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO3 value is below normal. The PaCO2 value and the oxygen saturation level are within a normal range.
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? pH, 7.35; PaCO2 70 mm Hg pH, 7.29; PaCO2 30 mm Hg pH, 7.25; PaCO2 50 mm Hg pH, 7.5; PaCO2 30 mm Hg
pH, 7.25; PaCO2 50 mm Hg Explanation: In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.
The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis? pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.
Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting? pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34 pH: 7.45, PWhen evaluating a client's arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? HCO3 21 mEq/L PaCO2 36 pH 7.48 O2 saturation 95%aCO2: 32 mm Hg, HCO3-: 21
pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.
For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to: prevent respiratory alkalosis. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg. promote carbon dioxide elimination. lower arterial pH.
prevent respiratory alkalosis. Correct response: promote carbon dioxide elimination. Explanation: The goal of treatment for ICP is to prevent acidemia by eliminating carbon dioxide because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this client. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.
A client appears flushed and has shallow respirations. The arterial blood gas report shows the following: pH, 7.24; partial pressure of arterial carbon dioxide (PaCO2), 49 mm Hg (6.5 kPa); bicarbonate (HCO3-), 24 mEq/L (24 mmol/L). These findings are indicative of which acid-base imbalance?
respiratory acidosis Explanation: The pH of 7.24 indicates that the client is acidotic. The PaCO2 value of 49 mm Hg is elevated. The HCO3- value of 24 mEq/L is normal. The client is in uncompensated respiratory acidosis. Hypoventilation and a flushed appearance are additional clinical manifestations of respiratory acidosis.
A client has a dull headache, is dizzy, and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH 7.26; partial pressure of carbon dioxide, 50 mm Hg (6.7 kPa); and bicarbonate, 24 mEq/L (24 mmol/L). These findings indicate which acid-base imbalance? respiratory alkalosis metabolic alkalosis metabolic acidosis respiratory acidosis
respiratory acidosis Explanation: The pH of 7.26 indicates that the body is in a state of acidosis. The elevated partial pressure of carbon dioxide value accompanied by a normal bicarbonate value indicates that the acid-base imbalance is respiratory acidosis. The additional clinical findings of headache, dizziness, and increased pulse rate, resulting from the elevated partial pressure of carbon dioxide, further support this diagnosis.
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of: acute CNS disturbances respiratory alkalosis metabolic acidosis increased PaCO2
respiratory alkalosis Explanation: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation, which does not cause metabolic acidosis. Acute CNS disturbances result from multiple potential causes. Increased carbon dioxide levels are associated with acidosis, not alkalosis.
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: metabolic acidosis. metabolic alkalosis. respiratory acidosis. respiratory alkalosis.
respiratory alkalosis. Explanation: This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: respiratory alkalosis. metabolic acidosis. metabolic alkalosis. respiratory acidosis.
respiratory alkalosis. Explanation: This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.
When caring for a 12-month-old infant with dehydration and metabolic acidosis, the nurse expects to see: a reduced white blood cell (WBC) count. a decreased platelet count. tachypnea. shallow respirations.
tachypnea. Explanation: The nurse would expect to see tachypnea because the body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations. Altered WBC and platelet counts aren't specific signs of metabolic imbalance.
When caring for a 12-month-old infant with dehydration and metabolic acidosis, the nurse expects to see: shallow respirations. a reduced white blood cell (WBC) count. a decreased platelet count. tachypnea.
tachypnea. Explanation: The nurse would expect to see tachypnea because the body compensates for metabolic acidosis via the respiratory system, which tries to eliminate the buffered acids by increasing alveolar ventilation through deep, rapid respirations. Altered WBC and platelet counts aren't specific signs of metabolic imbalance.
