SAUNDERS NCLEX-RN ACID BASE
A client has a prescription for arterial blood gas (ABG) analysis on radial artery specimens. The nurse ensures that which intervention has been performed or tested before the ABG specimens are drawn? 1.Allen's test 2.Goodell's sign 3.Babinski reflex 4.Brudzinski's sign
1.Allen's test Rationale: Before radial artery puncture for obtaining a blood sample for ABG analysis, an Allen test should be performed to determine adequate ulnar circulation. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. Goodell's sign is used during pregnancy and indicates a softening of the cervix at the beginning of the second month of pregnancy. The Babinski reflex is checked by stroking upward on the sole of the foot. Brudzinski's sign is nuchal rigidity on bending the head down toward the chest.
A nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse understands that as the client's CO2 level rises, what will occur with the blood pH? 1.Fall 2.Rise 3.Double 4.Remain unchanged
1.Fall Rationale: CO2 acts as an acid in the body. A rise in blood CO2 will result in a fall in pH. The other options are incorrect.
A nurse reviews the arterial blood gas results of a client with Guillain-Barré syndrome. The pH is 7.34 and the Pco2 is 50 mm Hg. Which acid-base imbalance should the nurse interpret that this client is experiencing? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
3.Respiratory acidosis Rationale: The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is low and the Pco2 is elevated. This is an expected finding in a client with a neuromuscular disorder such as Guillain-Barré syndrome because the client may retain carbon dioxide as a result of ventilatory failure as paralysis ensues.
The nurse notes that a client's arterial blood gas results reveal a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these arterial blood gas results? Select all that apply. 1.Nausea 2.Confusion 3.Bradypnea 4.Tachycardia 5.Hyperkalemia 6.Lightheadedness
1.Nausea 2.Confusion 4.Tachycardia 6.Lightheadedness Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs.
A client has a prescription for a set of arterial blood gas (ABGs) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action? 1.Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. 2.Change the nasal cannula to a shovel face mask; then have the ABG samples drawn. 3.Leave the nasal cannula in place for 15 minutes; then have the ABG samples drawn. 4.Change the nasal cannula to a Venturi face mask; then have the ABG samples drawn.
1.Remove the nasal cannula for 15 minutes; then have the ABG samples drawn. Rationale: The client should have oxygen supplementation removed for at least 15 minutes before ABGs are drawn if the client has a prescription for the ABGs to be drawn on room air. This allows time for the client's system to equilibrate so that the ABG results will accurately reflect ventilatory status without the supplemental oxygen. This prescription may be given when the health care provider is trying to decide whether to discontinue oxygen therapy, and it allows staff to observe how the client tolerates oxygen removal. Therefore the remaining options are incorrect.
The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1.pH 7.25, Pco2 50 mm Hg 2.pH 7.35, Pco2 40 mm Hg 3.pH 7.50, Pco2 52 mm Hg 4.pH 7.52, Pco2 28 mm Hg
1.pH 7.25, Pco2 50 mm Hg Rationale: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the Pco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.
A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1.Bradycardia and hyperactivity 2.Decreased respiratory rate and depth 3.Headache, restlessness, and confusion 4.Bradypnea, dizziness, and paresthesias
3.Headache, restlessness, and confusion Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.
The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
2.Metabolic alkalosis Rationale: Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. The remaining acid-base disturbances are incorrect.
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
2.Metabolic alkalosis Rationale: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Pco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1.Sodium level of 145 mEq/L 2.Potassium level of 3.0 mEq/L 3.Magnesium level of 2.0 mg/dL 4.Phosphorus level of 4.0 mg/dL
2.Potassium level of 3.0 mEq/L Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.
A client has had an arterial blood gas sample drawn from the radial artery, and the nurse is asked to hold pressure on the site. The nurse should apply pressure for at least how many minute(s)? 1. 1 minute 2. 2 minutes 3. 5 minutes 4. 10 minutes
3. 5 minutes Rationale: After blood is drawn for arterial blood gas analysis, continuous pressure must be applied to the site. A radial artery site requires at least 5 minutes of pressure, whereas a femoral artery site requires 10 minutes. A small pressure dressing often is placed on the site after this time period. When the client is receiving anticoagulant therapy, application of pressure for a longer period may be needed.
A nurse is admitting a client with a diagnosis of Guillain-Barré syndrome to the hospital. The nurse knows that if the disease is severe enough, the client will be at risk for which acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
3.Respiratory acidosis Rationale: Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, leading to respiratory acidosis and ventilatory failure as the paralysis develops. Therefore, options 1, 2, and 4 are incorrect.
The nurse is reviewing the arterial blood gas (ABG) values of a client and notes that the pH is 7.31, Pco2 is 50 mm Hg, and the bicarbonate (HCO3) level is 27 mEq/L. The nurse concludes that which acid-base disturbance is present in this client? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
3.Respiratory acidosis Rationale: In respiratory acidosis the pH is decreased and the Pco2 level is increased. Options 1, 2, and 4 are incorrect. In respiratory alkalosis, the pH is elevated with a decrease in Pco2. In metabolic acidosis, both the pH and the HCO3 are decreased. In metabolic alkalosis, the pH and HCO3 are increased.
The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Pco2 of 58 mm Hg, Po2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
3.Respiratory acidosis Rationale: The normal pH is 7.35 to 7.45. Normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Pco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.
The nurse reviews the arterial blood gas (ABG) results of an assigned client and notes that the laboratory report indicates a pH of 7.30, a Pco2 of 58 mm Hg, a Po2 of 80 mm Hg, and an Hco3 of 27 mEq/L. The nurse should interpret this to mean that the client has which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
3.Respiratory acidosis Rationale: The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and the Pco2 is elevated. In respiratory alkalosis, an opposite effect occurs; the pH is elevated and the Pco2 is low. In metabolic acidosis, the pH is low and the bicarbonate is low; in metabolic alkalosis, the opposite effect occurs.
A nurse reviews a client's arterial blood gas values and notes a pH of 7.50, a Pco2 of 30 mm Hg, and an HCO3 of 25 mEq/L. The nurse should interpret these values as an indication of which condition? 1.Metabolic acidosis, uncompensated 2.Respiratory acidosis, uncompensated 3.Respiratory alkalosis, uncompensated 4.Metabolic acidosis, partially compensated
3.Respiratory alkalosis, uncompensated Rationale: In respiratory alkalosis, the pH will be higher than normal and the Pco2 will be low. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. The correct option is the only one that reflects these conditions.
The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30, the Pco2 is 52 mm Hg, and the HCO3 is 22 mEq/L. The nurse interprets these results as indicating which condition? 1.Metabolic acidosis, compensated 2.Respiratory alkalosis, compensated 3.Metabolic alkalosis, uncompensated 4.Respiratory acidosis, uncompensated
4.Respiratory acidosis, uncompensated Rationale: Normal pH is 7.35 to 7.45. In a respiratory condition, the pH and the Pco2 will exhibit opposite effects; in this case, the pH is low and the Pco2 is increased. In an acidotic condition, the pH is decreased. Therefore the values identified in the question indicate a respiratory acidosis. Compensation occurs when the pH returns to a normal value. Because the pH is not within the normal range, the condition is uncompensated.
An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1.Headache and tachypnea 2.Hyperactivity and dyspnea 3.Muscle twitches and cyanosis 4.Lightheadedness and paresthesias
4.Lightheadedness and paresthesias Rationale: Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. Options 1, 2, and 3 are not clinical manifestations of respiratory alkalosis.
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3 is 22 mEq/L. The nurse interprets the results as indicating which condition? 1.Metabolic acidosis with compensation 2.Respiratory acidosis with compensation 3.Metabolic acidosis without compensation 4.Respiratory acidosis without compensation
4.Respiratory acidosis without compensation Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate (HCO3) level is 22 to 27 mEq/L. Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore the condition is without compensation. The remaining options are incorrect interpretations.
In a client seen in the health care clinic, arterial blood gas analysis gives the following results: pH 7.48, Pco2 32 mm Hg, Po2 94 mm Hg, HCO3 level 24 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
4.Respiratory alkalosis Rationale: The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg, and the normal HCO3 concentration is 22 to 27 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In a metabolic condition, the pH and the bicarbonate move in the same direction.
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCO3 of 20 mEq/L. The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3.Metabolic alkalosis, uncompensated 4.Respiratory acidosis, uncompensated
2. Respiratory alkalosis, compensated Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.
The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse assesses this client for which signs/symptoms that are characteristic of this disorder? 1.Bradycardia and hyperactivity 2.Decreased respiratory rate and depth 3.Headache, restlessness, and confusion 4.Bradypnea, dizziness, and paresthesias
3.Headache, restlessness, and confusion Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache, restlessness, and mental status changes such as drowsiness and confusion, visual disturbances, diaphoresis, and cyanosis as the hypoxia becomes more acute, hyperkalemia, a rapid irregular pulse, and dysrhythmias.
The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit and notes a pH of 7.38, PaCO2 of 38 mm Hg, PaO2 of 86 mm Hg, and HCO3 of 23 mEq/L. The nurse interprets that these values indicate which result? 1.Normal results 2.Metabolic acidosis 3.Metabolic alkalosis 4.Respiratory acidosis
1.Normal results Rationale: The client's results fall in the normal range for pH (7.35 to 7.45), PaCO2 (35 to 45 mm Hg), and bicarbonate level (22 to 26 mEq/L). With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be high with respiratory acidosis, whereas bicarbonate levels would be low if metabolic acidosis were present.
The nurse plans care for a client with chronic obstructive pulmonary disease (COPD), understanding that the client is most likely to experience what type of acid-base imbalance? 1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis
3.Respiratory acidosis Rationale: Respiratory acidosis is most often caused by hypoventilation in a client with COPD. Other acid-base disturbances can occur in a client with COPD during exacerbation of the disease, but the most likely imbalance is respiratory acidosis. The remaining options are incorrect. COPD is a respiratory condition, not a metabolic one. Respiratory alkalosis is associated with hyperventilation.
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1.A decreased pH and an increased CO2 2.An increased pH and a decreased CO2 3.A decreased pH and a decreased HCO3 4.An increased pH with an increased HCO3
4.An increased pH with an increased HCO3 Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3 to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.
