Prep U Acid-Base Balance
A patient presents to the Emergency Department experiencing a severe anxiety attack and is hyperventilating. The nurse would expect the patient's pH value to be which of the following? a) 7.45 b) 7.30 c) 7.50 d) 7.35
7.50
Which assessment findings would the nurse expect to find in the postoperative client experiencing fat embolism syndrome? a) HR 92, RR 20, pH 7.32, CO2 35, HCO2 20, PaCO2 62 b) HR 116, RR32, pH 7.50, CO2 30, HCO2 24, PaO2 55 c) HR 88 RR 16, pH 7.48, CO2 43, HCO2 28, PaO2 85 d) HR 102, RR 26, pH 7.45, CO2 37, HCO2 23, PaO2 72
Column B Explanation: Fat embolism syndrome is characterized by fever, tachycardia, tachypnea, and hypoxia. Arterial blood gas findings include a partial pressure of oxygen (PaO2) less than 60 mm Hg, with early respiratory alkalosis and later respiratory acidosis.
A neonate is born 8 weeks premature. At birth, he has no spontaneous respirations, but he is successfully resuscitated. Within several hours he develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. He's diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the neonate's care plan to prevent retinopathy of prematurity? a) Cover his eyes while receiving oxygen. b) Humidify the oxygen. c) Monitor partial pressure of oxygen (PaO2) levels. d) Keep his body temperature low.
Monitor partial pressure of oxygen (PaO2) levels. Correct Explanation: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature neonate receiving oxygen. Covering the neonate's eyes and humidifying the oxygen don't reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the neonate should be kept warm so that his respiratory distress isn't aggravated.
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? a) Prepare for gastric lavage. b) Prepare to assist with ventilation. c) Monitor the client's heart rhythm. d) Obtain a urine specimen for drug screening.
Prepare to assist with ventilation. Correct 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.
Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation? a) 10 minutes b) 25 minutes c) 15 minutes d) 20 minutes
20 minutes
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, 7.25; PaCO2 50 mm Hg
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? a) Offer the client fluids frequently. b) Administer ordered supplemental oxygen. c) Administer an ordered decongestant. d) Instruct the client to breathe into a paper bag.
Instruct the client to breathe into a paper bag. Correct 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 hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? a) Light-headedness or paresthesia b) Nausea or vomiting c) Hallucinations or tinnitus d) Abdominal pain or diarrhea
Light-headedness or paresthesia Correct 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.
Which sign is an early indicator of hypoxia in the unconscious client? a) cyanosis b) hypotension c) decreased respirations d) restlessness
restlessness Explanation: Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in the unconscious client who becomes restless. The most accurate method for determining the presence of hypoxia is to evaluate the pulse oximeter value or arterial blood gas values. Cyanosis and decreased respirations are late indicators of hypoxia. Hypertension, not hypotension, is a sign of hypoxia
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?
Arterial blood gas (ABG) findings
Which physical sensation will the client who has had an abdominal hysterectomy most likely experience if she hyperventilates while performing deep-breathing exercises? a) mental confusion b) dyspnea c) dizziness d) blurred vision
Dizziness
A client has been hospitalized with myxedema coma. What acid-base imbalance would be expected in this client?
Respiratory acidosis 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 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? a) The oxygen level is low but poses no risk for the client. b) The client requires oxygen therapy with very low oxygen concentrations. c) `The client is severely hypoxic. d) The client's PaO2 level is within normal range.
The client is severely hypoxic
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:
improving respiratory status.
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? a) Hematocrit values b) Pulmonary function c) Hemoglobin levels d) Arterial blood gas
Arterial blood gas Explanation: Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids
The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first: a) prepare for intubation. b) institute rewarming. c) start an intravenous infusion. d) administer oxygen
administer oxygen. Correct 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.
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? a) Extreme anxiety b) Myasthenia gravis c) Type 1 diabetes mellitus d) Opioid overdose
Extreme Anxiety
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? a) Myasthenia gravis b) Extreme anxiety c) Type 1 diabetes mellitus d) Opioid overdose
Extreme anxiety Correct 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? a) Ineffective airway clearance b) Metabolic acidosis c) Deficient fluid volume d) Impaired gas exchange
Impaired gas exchange Correct 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.
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? a) Respiratory acidosis b) Metabolic alkalosis c) Respiratory alkalosis d) Metabolic acidosis
Metabolic alkalosis Correct 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 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? a) `The client is severely hypoxic. b) The client's PaO2 level is within normal range. c) The client requires oxygen therapy with very low oxygen concentrations. d) The oxygen level is low but poses no risk for the client.
`The client is severely hypoxic. Correct 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).
For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which acid-base imbalance? a) respiratory alkalosis b) metabolic acidosis c) metabolic alkalosis d) respiratory acidosis
metabolic alkalosis Correct Explanation: Metabolic alkalosis occurs because of the excessive loss of potassium, hydrogen, and chloride in the vomitus. Chloride loss leads to a compensatory increase in the number of bicarbonate ions. The bicarbonate side of the carbonic acid-base bicarbonate increases, and the pH becomes more alkaline. Respiratory alkalosis is caused by conditions such as hyperventilation that result in loss of partial pressure of arterial carbon dioxide (PaCO2). Respiratory acidosis is caused by conditions such as inadequate ventilation that result in excessive retention of PaCO2. Metabolic acidosis results from the loss of large amounts of bicarbonate, such as with severe diarrhea.
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. a) Compare ABG findings with previous results. b) Suction the client's airway. c) Maintain intake and output records. d) Document presenting signs and symptoms. e) Administer IV bicarbonate.
• Compare ABG findings with previous results. • Maintain intake and output records. • Document presenting signs and symptoms. Correct 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 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 1 oz = 30 mL
The nurse is caring for a client with a metabolic acidosis (pH 7.25). Which of the following values is most useful to the nurse in determining whether the cause of the acidosis is due to acid gain or to bicarbonate loss? a) Serum sodium level b) Anion gap c) PaCO2 d) PaO2
Anion gap Correct Explanation: Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration. It can be produced by a gain of hydrogen ion or a loss of bicarbonate. It can be divided clinically into two forms, according to the values of the serum anion gap: high anion gap acidosis and normal anion gap acidosis. A patient diagnosed with metabolic acidosis is determined to have normal anion gap metabolic acidosis if the anion gap is within this normal range. An anion gap greater than 16 mEq (16 mmol/L) (the normal value for an anion gap is 8-12 mEq/L (8-12 mmol/L) without potassium in the equation. If potassium is included in the equation, the normal value for the anion gap is 12-16 mEq/L (12-16 mmol/L) and suggests an excessive accumulation of unmeasured anions and would indicate high anion gap metabolic acidosis as the type. An anion gap occurs because not all electrolytes are measured. More anions are left unmeasured than cations. A low or negative anion gap may be attributed to hypoproteinemia. Disorders that cause a decreased or negative anion gap are less common compared to those related to an increased or high anion gap.
Which stage of shock would encompass mechanical ventilation, altered level of consciousness, and profound acidosis?
Irreversible Explanation: The irreversible stage encompasses use of mechanical ventilation, altered consciousness, and profound acidosis. The compensatory stage encompasses decreased urinary output, confusion, and respiratory alkalosis. The progressive stage involves metabolic acidosis, lethargy, rapid, shallow respirations. There is not a stage of shock called the precompensatory stage.
The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first:
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
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. a) HCO3 b) Na+ c) K+ d) Nitrogen e) PaCO2 f) pH
• HCO3 • PaCO2 • pH 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 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? a) Respiratory alkalosis b) Metabolic acidosis c) Respiratory acidosis d) Metabolic 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 with AIDS has developed cytomegalovirus (CMV) retinitis and is receiving treatment with foscarnet. The nurse would monitor for which possible adverse drug effects? Select all that apply.
• Hyperphosphatemia • Hypomagnesemia • Seizures
Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes?
Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. The hazard of severe hypoglycemia with alcohol consumption is stressed to the client and family. When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. A standard treatment with pancreatitis is to make the client NPO. The dysfunction is related to the pancreas, not the liver
As part of the process of checking the placement of a nasogastric tube, the nurse checks the pH of the aspirate. Which pH finding would indicate to the nurse that the tube is in the stomach? a) 4 b) 10 c) 6 d) 8
4 Correct Explanation: Gastric secretions are acidic and have a pH ranging from 1 to 5. Intestinal aspirate is typically 6 or higher; respiratory aspirate is more alkaline, usually 7 or greater.
A nurse is caring for a 3-year-old client with a neuroblastoma who has been receiving chemotherapy for the last 4 weeks. His laboratory test results indicate a Hgb of 12.5 g/dL (125 g/L), HCT of 36.8% (0.37), WBC of 2000 mm3 (2 X 109/L), and platelet count of 150,000/μL (150 X 109/L). Based on the child's values, what is the highest priority nursing intervention?
Encourage meticulous handwashing by the client and visitors.
Which of the following medications is classified as a proton pump inhibitor (PPI)? a) Omeprazole b) Ranitidine c) Famotidine d) Cimetidine
Omeprazole Correct Explanation: Omeprazole is classified as a PPI. Ranitidine, Cimetidine, and Famotidine are classified as H2 receptor antagonists.
Which of the following medications is classified as a proton pump inhibitor (PPI)?
Omeprazole is classified as a PPI. Ranitidine, Cimetidine, and Famotidine are classified as H2 receptor antagonists.
A client presents to the ED in shock. During what phase of shock does the nurse know that metabolic acidosis is going to most likely occur? a) Irreversible b) Compensation c) Decompensation d) Early
The decompensation stage occurs as compensatory mechanisms fail. The client's condition spirals Into cellular hypoxia, coagulation defects, and cardiovascular changes. As the energy supply falls below the demand, pyruvic and lactic acids increase, causing metabolic acidosis.
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? a) Risk factor b) Morbidity c) Exacerbation d) Infection
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.
A recently extubated client has shortness of breath. The nurse reports the client's discomfort and the results of the recently prescribed arterial blood gas analysis to the health care provider (HCP). After reviewing the report of the complete blood count (see report), the nurse should also report which results to the HCP? a) hemoglobin and hematocrit b) PT c) HA1c d) monocytes
hemoglobin and hematocrit Explanation: The nurse should review the CBC with differential to evaluate the client's hemoglobin and hematocrit, which are abnormal and should be reported to the HCP. Anemia leads to decreased oxygen-carrying capacity of the blood. A client unable to compensate for the anemia may experience a profound sense of dyspnea. There has been a significant drop in the hemoglobin and hematocrit since the previous report, and these should be reported to the HCP. The monocytes are within normal range. HA1c is a laboratory test evaluating glycosylated hemoglobin and is in the normal range. This test is used to diagnose diabetes and/or monitor diabetic glucose control over time. PT is a coagulation study reflecting liver function and clotting time and is in the normal range.
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 Correct 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 assessing a child with ketoacidosis. The nurse should particularly observe if the client has: a) diaphoretic, warm skin. b) slow, bounding pulse rate. c) deep, rapid respirations. d) elevated blood pressure.
deep, rapid respirations. Correct 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.
A nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the client's blood? a) PaCO2 b) pH c) HCO3- d) PaO2
pH Correct 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.
A client has the following arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition? a) Metabolic acidosis b) Respiratory alkalosis c) Respiratory acidosis d) Metabolic alkalosis
Respiratory acidosis Explanation: This client has a below-normal (acidic) blood pH value and an above-normal partial pressure of arterial carbon dioxide (PaCO2) value, indicating respiratory acidosis. In respiratory alkalosis, the pH value is above normal and the PaCO2 value is below normal. In metabolic acidosis, the pH and bicarbonate (HCO3-) values are below normal. In metabolic alkalosis, the pH and HCO3- values are above normal.
Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes melitus. Which of the following explains the cause of this secondary diabetes? a) Inability for the liver to reabsorb serum glucose b) Ingestion of foods high in sugar c) Dysfunction of the pancreatic islet cells d) Renal failure
Dysfunction of the pancreatic islet cells Correct Explanation: Diabetes mellitus resulting from dysfunction of the pancreatic islet cells is treated with diet, insulin, or oral antidiabetic agents. The hazard of severe hypoglycemia with alcohol consumption is stressed to the client and family. When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. A standard treatment with pancreatitis is to make the client NPO. The dysfunction is related to the pancreas, not the liver.
The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially? a) Respiratory alkalosis b) Metabolic acidosis c) Metabolic alkalosis d) Respiratory acidosis
Respiratory alkalosis Explanation: At first, arterial blood gas analysis may reveal respiratory alkalosis as a result of rapid, shallow breathing. Later, there is a shift to metabolic acidosis as gas exchange becomes more impaired. Respiratory acidosis and metabolic alkalosis are incorrect distractors.
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? a) Metabolic acidosis b) Respiratory acidosis c) Respiratory alkalosis d) Metabolic alkalosis
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)
An adolescent is admitted for treatment of bulimia nervosa. When developing the care plan, the nurse anticipates including interventions that address which metabolic disorder? a) Metabolic acidosis b) Hyperkalemia c) Hypoglycemia d) 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.
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? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic alkalosis d) 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 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? a) Respiratory acidosis b) Metabolic acidosis c) Respiratory alkalosis d) Metabolic alkalosis
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
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?
The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions
A patient diagnosed AKI has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering which of the following? a) Sorbitol b) Calcium supplements c) IV dextrose 50% d) Kayexalate
The elevated potassium levels may be reduced by administering cation-exchange resins (sodium polystyrene sulfonate [Kayexalate]) orally or by retention enema. Kayexalate works by exchanging sodium ions for potassium ions in the intestinal tract. Sorbitol may be administered in combination with Kayexalate to induce a diarrhea-type effect (it induces water loss in the GI tract). If the patient is hemodynamically unstable (low blood pressure, changes in mental status, dysrhythmia), IV dextrose 50%, insulin, and calcium replacement may be administered to shift potassium back into the cells.
You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from? a) The trachea and bronchi b) A puncture at the radial artery c) A catheter in the arm vein d) The pleural surfaces
A puncture at the radial artery Correct Explanation: ABGs determine the blood's pH; oxygen-carrying capacity; and levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? a) Absence of protein b) Urine pH of 3.0 c) Absence of glucose d) Specific gravity of 1.03
Urine pH of 3.0 Correct 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.
When evaluating a client's arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? a) O2 saturation 95% b) pH 7.48 c) HCO3 21 mEq/L d) PaCO2 36
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.
pH 7.34 HCO3 19 PaCO2 35 PaO2 5.3 K+ 5.3 Cl- 102 Ca+ 10.4 Anion gap 30 The nurse is admitting a client with newly diagnosed diabetes mellitus and left-sided heart failure. Assessment reveals low blood pressure, increased respiratory rate and depth, drowsiness, and confusion. The client reports headache and nausea. Based on the serum laboratory results below, how would the nurse interpret the client's acid-base balance? a) Respiratory acidosis. b) Metabolic acidosis. c) Respiratory alkalosis. d) Metabolic alkalosis.
Metabolic acidosis. Correct 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.
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? a) Heart and lungs b) Kidneys and liver c) Pancreas and heart d) Lungs and kidneys
Lungs and kidneys Explanation: The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate 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: a) are unable to exchange oxygen and carbon dioxide. b) are unable to inspire sufficient oxygen. c) are not able to blow off carbon dioxide. d) have ineffective cilia from years of smoking.
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.
Which of the following is the priority nursing diagnosis for the patient undergoing a laryngectomy? a) Anxiety and depression b) Impaired verbal communication c) Ineffective airway clearance d) Imbalanced nutrition: Less than body requirements
Ineffective airway clearance Explanation: The priority nursing diagnosis is Ineffective airway clearance, utilizing the ABCs. Imbalanced nutrition: Less than body requirement, impaired verbal communication, and anxiety and depression are all potential nursing diagnoses, but they are not the priority diagnosis.
