Assessment r/t Acid Base Imbalance
Which should the nurse assess for in all patients who are experiencing an acid-base imbalance? urine output ABG analysis vital signs bowel sounds skin turgor
ABG Analysis vital signs
Which should the nurse assess for in all patients who are experiencing an acid-base imbalance? Select all that apply. Urine output ABG analysis Vital signs Bowel sounds Skin turgor
ABG Analysis Vital Signs
Which PaO2 value indicates moderate hypoxemia? 20-40 mmHg 40-60 mm Hg 60-80 mm Hg 80-100 mm Hg
40-60 mmHg indicates mild hypoxemia
Which neurological clinical manifestations are associated with metabolic acidosis? Select all that apply. Nausea Confusion Lethargy Vomiting Anorexia
confusion lethargy
Which nursing actions should the nurse perform when analyzing an ABG during the assessment process for a patient who is suspected of having an acid-base imbalance? examining oxygen status evaluating pH assessing PaCo2 and HCO3- monitoring potassium determining compensation
examining oxygen status evaluating pH assessing PaCo2 and HCO3- determining compensation
Which assessment finding causes the nurse to suspect that a patient is experiencing metabolic acidosis? dyspnea Kussmaul respirations polyuria muscle twitching
kussmaul respirations Kussmaul respirations are frequent, deep breaths that constitute a compensatory mechanism in an effort to breathe out more carbon dioxide. This is an assessment finding that would cause the nurse to suspect that the patient is experiencing metabolic acidosis.
The nurse is providing care to a patient with the following ABG values: pH 7.30, PaCO2 40 mm Hg, and HCO3- 20 mEq/L. Which should the nurse document in the medical record regarding this ABG? respiratory acidosis respiratory alkalosis metaboliz acidosis metabolic alkalosis
metabolic acidosis
A patient presents with muscle twitching and tetany. Ten minutes after hospital admission, the patient experiences a seizure. Which acid-base imbalance should the nurse suspect? Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory acidosis
metabolic alkalosis
A patient presents with muscle twitching and tetany. Ten minutes after hospital admission, the patient experiences a seizure. Which acid-base imbalance should the nurse suspect? metabolic alkalosis metabolic acidosis respiratory alkalosis respiratory acidosis
metabolic alkalosis
The nurse is evaluating the ABG results for a patient who is suspected of having an acid-base imbalance. The ABG analysis indicates a decreased pH, an increased PaCO2, and a normal HCO3-. Which conclusion by the nurse is accurate? respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis
respiratory acidosis
Which acid-base imbalance manifests with tachypnea and light-headedness? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis
respiratory alkalosis
The nurse is assessing a patient who is diagnosed with respiratory acidosis. Which cardiovascular finding does the nurse anticipate when assessing the cardiovascular system? tachycardia dysrhythmia hypotension dyspnea confusion
tachycardia dysrhythmia
Which clinical manifestation does the nurse anticipate when assessing a patient who is experiencing respiratory alkalosis? dyspnea tachypnea hypertension hypotension
tachypnea