Ch 9 Acid-Base Balance

A client is transferred to the postanesthesia care unit after abdominal surgery. The client begins vomiting. What nursing action is most important when caring for this client? A. Turning the client onto the side B. Measuring the amount of vomitus C. Checking the wound for dehiscence D. Administering the prescribed antiemetic to the client

A. The side-lying position promotes drainage of emesis and secretions from the mouth, reducing the risk of aspiration. Although accurate assessment of intake and output is important, prevention of aspiration is the priority. Dehiscence is not probable at this time; it is more common five to seven days after surgery. Although the antiemetic may prevent additional vomiting, the nurse's priority is to prevent aspiration.

A client who has been experiencing chest pain and vomiting for several hrs is admitted to the hospital with a diagnosis of myocardial infarction. The client is transferred immediately to the cardiac intensive care unit. The client's potassium level is below the expected range. Considering this laboratory result, what should the nurse monitor the client's electrocardiogram (ECG) for? A. Tall, peaked P waves B. Increased P-R intervals C. Elevated U and flattened T waves D. Multiple trigeminy and bigeminy runs

C. Elevated U and flattened T waves reflect low serum potassium levels. U waves are not expected; they signify repolarization of the terminal Purkinje fibers and are seen with hypokalemia. T waves represent ventricular repolarization; T waves flatten with hypokalemia and peak with hyperkalemia. Changes in P waves reflect atrial depolarization and contraction activity; P waves flatten with hyperkalemia, not hypokalemia. Increased P-R intervals are related to a delay in conduction from the sinoatrial (SA) node to the ventricles and are not altered with hypokalemia. Trigeminy and bigeminy reflect ventricular irritability, not the serum potassium level.

The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis? Select all that apply. A. Confusion B. Hyperactivity C. Excessive thirst D. Fruit-scented breath E. Decreased urinary output

A, C, D. Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body produces high levels of ketones (blood acids). DKA develops when the body is unable to produce enough insulin. Without enough insulin, the body begins to break down fat as an alternative fuel. This process produces a buildup of ketones (toxic acids) in the bloodstream, eventually leading to DKA if untreated. Signs and symptoms include excessive thirst, frequent urination, nausea and vomiting, abdominal pain, weakness or fatigue, shortness of breath, fruity-scented breath, and confusion. Frequent urination, not decreased urination, is a symptom. Weakness or fatigue, not hyperactivity, is a symptom.

A client has a fractured mandible that is immobilized with wires. For which life-threatening postoperative problem should the nurse monitor this client? A. Infection B. Vomiting C. Osteomyelitis D. Bronchospasm

B. Vomiting may result in aspiration of vomitus, because it cannot be expelled; this may cause pneumonia or asphyxia. Infection, osteomyelitis, and bronchospasm generally are not life-threatening problems.

The nurse is caring for a client with emphysema. During assessment, the nurse expects to auscultate which type of breath sounds? A. Pleural friction rub B. Crackles and gurgles C. Diminished breath sounds D. Expiratory wheeze and cough

C. Breath sounds will be decreased in clients with emphysema because of reduced airflow, pleural effusion, or lung parenchymal destruction. A pleural friction rub occurs when one layer of the pleural membrane slides over the other during breathing; this is associated with pleurisy. Crackles indicate fluid in the alveoli, which is associated with HF or infection; rhonchi signify airway obstruction, not emphysema. Expiratory wheezing and coughing are associated with asthma or bronchitis.

A nurse is caring for an infant with severe dehydration. Which blood gas report most likely reflects the acid-base balance of this infant? A. pH of 7.50 and PCO2 of 34 mm Hg B. pH of 7.23 and PCO2 of 70 mm Hg C. pH of 7.20 and HCO3 of 30 mEq/L D. pH of 7.56 and HCO3 of 30 mEq/L

C. Low blood pH and bicarbonate levels indicate metabolic acidosis, which occurs with severe dehydration because the reduced urine output causes retention of hydrogen ions. The other options include findings that indicate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis, respectively.

A client s admitted to the emergency department with multiple injuries, including fractured ribs. Which assessment is priority? A. Pneumonitis B. Hematemesis C. Pulmonary edema D. Respiratory acidosis

D. Fractured ribs cause extreme pain, especially on inhalation; this induces shallow breathing, which results in carbon dioxide retention, leading to respiratory acidosis. Although decreased respiratory functioning can result in an infection, respiratory acidosis is the immediate concern. Blood in vomitus (hematemesis) is unrelated to fractured ribs; hemoptysis will be more important than hematemesis. Pulmonary edema is unrelated to fractured ribs; it is associated with HF or fluid overload.