acid base
he nurse is developing a care plan with an older adult with hypertension and is instructing the client that hypertension can be a "silent killer." The nurse should instruct the client to report signs of which of the following diseases that are often a result of undetected high blood pressure? a) Liver disease. b) Cerebrovascular accidents (CVAs). c) Pulmonary disease. d) Myocardial infarction.
Cerebrovascular accidents (CVAs). Explanation: Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, the hypertension may go undetected. CVAs can be related to long-term hypertension. Liver or pulmonary disease is not generally associated with hypertension. Myocardial infarction is generally related to coronary artery disease.
When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? a) Aching pain in the left calf. b) Coldness of the left foot and ankle. c) Numbness and tingling in the left leg. d) Burning pain in the left calf.
Coldness of the left foot and ankle. Explanation: Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor. Aching pain, a burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated within incomplete obstruction.
While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the client's physician immediately if the client exhibited which of the following?
Dyspnea. Explanation: A major complication of deep vein thrombosis is pulmonary embolism. Signs and symptoms, which may occur suddenly and require immediate treatment, include dyspnea, severe chest pain, apprehension, cough (possibly accompanied by hemoptysis), tachycardia, fever, hypotension, diaphoresis, pallor, shortness of breath, and friction rub. Pain in the calf is common with a diagnosis of deep vein thrombosis. Hypotension, not hypertension, would suggest a possible pulmonary embolism. It also could suggest possible hemorrhage secondary to intravenous heparin therapy. Bradycardia for the first 7 days in the postpartum period is normal
A client is receiving intravenous (IV) heparin for the treatment of thrombophlebitis. Which laboratory value should the nurse monitor throughout heparin therapy? Select all that apply. a) Sodium level b) Partial thromboplastin time (PTT) c) Prothrombin time (PT) d) International Normalized Ratio (INR) e) Platelet count
Partial thromboplastin time (PTT) • Platelet count Explanation: Heparin is at a therapeutic level when PTT is 1 to 2 times the control. Therefore, the nurse should monitor PTT throughout heparin therapy. An adverse reaction associated with heparin is thrombocytopenia, so the nurse should also monitor platelet count. INR and PT should be obtained before initiating heparin therapy, but it is not necessary to monitor these values throughout therapy. Sodium levels do not have to be monitored routinely during heparin therapy.
The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is: a) Increased blood flow. b) Decreased blood flow. c) Thrombus formation. d) Slow blood flow.
Decreased blood flow. Explanation: Decreased blood flow is a common characteristic of all PVD. When the demand for oxygen to the working muscles becomes greater than the supply, pain is the outcome. Slow blood flow throughout the circulatory system may suggest pump failure. Thrombus formation can result from stasis or damage to the intima of the vessels
The nurse is assessing a client with chronic heart failure who is demonstrating neurohormonal compensatory mechanisms. Which of the following are expected findings on assessment? Select all that apply. a) Vasoconstriction in skin, GI tract, and kidneys b) Decreased cardiac output c) Decreased pulmonary perfusion d) Increased heart rate e) Fluid overload
Decreased cardiac output • Increased heart rate • Vasoconstriction in skin, GI tract, and kidneys • Fluid overload Explanation: Heart failure can result from several cardiovascular conditions that will affect the heart's ability to pump effectively. The body attempts to compensate through several neurohormonal mechanisms. Decreased cardiac output stimulates the aortic and carotid baroreceptors, which activates the sympathetic nervous system to release norepinephrine and epinephrine. This early response increases the heart rate and contractility. It also has some negative effects, including vasoconstriction of the skin, GI tract, and kidneys. Decreased renal perfusion (due to low CO and vasoconstriction) activates the renin-angiotensin-aldosterone process, resulting in the release of antidiuretic hormone. This causes fluid retention in an attempt to increase blood pressure, and therefore cardiac output. In the damaged heart, this causes fluid overload. There is no parasympathetic response. Decreased pulmonary perfusion can be a result of fluid overload or concomitant pulmonary disease
The nurse is assessing a client with chronic heart failure who is demonstrating neurohormonal compensatory mechanisms. Which of the following are expected findings on assessment? Select all that apply. a) Vasoconstriction in skin, GI tract, and kidneys b) Fluid overload c) Increased heart rate d) Decreased cardiac output e) Decreased pulmonary perfusion
Decreased cardiac output • Increased heart rate • Vasoconstriction in skin, GI tract, and kidneys • Fluid overload Explanation: Heart failure can result from several cardiovascular conditions that will affect the heart's ability to pump effectively. The body attempts to compensate through several neurohormonal mechanisms. Decreased cardiac output stimulates the aortic and carotid baroreceptors, which activates the sympathetic nervous system to release norepinephrine and epinephrine. This early response increases the heart rate and contractility. It also has some negative effects, including vasoconstriction of the skin, GI tract, and kidneys. Decreased renal perfusion (due to low CO and vasoconstriction) activates the renin-angiotensin-aldosterone process, resulting in the release of antidiuretic hormone. This causes fluid retention in an attempt to increase blood pressure, and therefore cardiac output. In the damaged heart, this causes fluid overload. There is no parasympathetic response. Decreased pulmonary perfusion can be a result of fluid overload or concomitant pulmonary disease.
The client has been managing episodes of angina with nitroglycerin. Which of the following indicates the drug is effective? a) Increased blood pressure. b) Decreased blood pressure. c) Decreased heart rate. d) Decreased chest pain (angina).
Decreased chest pain (angina). Explanation: Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation makes it easier for the heart to eject blood, resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by the heart muscle not receiving sufficient oxygen. While blood pressure may decrease ever so slightly as a result of the vasodilating effects of nitroglycerin, it is only secondary and not related to the client's angina. Increased blood pressure would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerin. (less)
A neonate weighing 1870 g with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11 has received sodium bicarbonate intravenously. The drug has been effective if the neonate: a) Develops respiratory alkalosis. b) Does not go into metabolic acidosis. c) Does not become edematous. d) Is not dehydrated.
Does not go into metabolic acidosis. Explanation: Metabolic acidosis results from the metabolic changes associated with cold stress. End products of metabolism increase the acidity of the blood, evidenced by a pH of 7.11. Therefore, sodium bicarbonate, which is a buffer base, is often used. Diuretics, not sodium bicarbonate, would be used to combat edema. Intravenous fluids would be used to treat dehydration. Respiratory alkalosis results from excessive carbon dioxide loss, a condition that would be unusual in this neonate. Additionally, because sodium bicarbonate is a base, administering it to client with alkalosis would only further exacerbate the alkalotic condition. (less)
The nurse should assess the client with left-sided heart failure for which of the following? (Select all that apply.) a) Right upper quadrant pain b) Jugular vein distention (JVD) c) Oliguria d) Decreased oxygen saturation levels e) Dyspnea f) Crackles
Dyspnea • Crackles • Oliguria • Decreased oxygen saturation levels Explanation: Dyspnea, crackles, oliguria, and decreased oxygen saturation are signs and symptoms related to pulmonary congestion and inadequate tissue perfusion associated with left-sided heart failure. JVD and right upper quadrant pain along with ascites and edema are usually associated with congestion of the peripheral tissues and viscera in right-sided heart failure
The nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease should be which of the following? a) Educate the client about his symptoms b) Decrease anxiety c) Administer sublingual nitroglycerin d) Enhance myocardial oxygenation
Enhance myocardial oxygenation Explanation: Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration is not the first priority. Although educating the client and decreasing anxiety are import in care delivery, neither is a priority when a client is compromised.
A nurse is caring for a young child with tetralogy of Fallot (TOF). The child is upset and crying. The nurse observes that he's dyspneic and cyanotic. Which position would help relieve the child's dyspnea and cyanosis? a) Lying flat in bed b) Sitting in bed with the head of the bed at a 45-degree angle c) Squatting d) Lying on his right side
Squatting Explanation: Placing the child in a squatting position sequesters a large amount of blood to the legs, reducing venous return. Sitting with the head of the bed at a 45-degree angle, lying flat, and lying on the right side don't reduce venous return; therefore, they won't relieve the child's dyspnea and cyanosis. A child with TOF may also assume a knee-chest position to reduce venous return to the heart.
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 Lispro insulin. The last meal was lunch, 2 hours ago. Place the following nursing actions in the order in which the nurse should perform them.
Start an I.V. infusion with normal saline solution. Obtain a fingerstick test for blood glucose. Notify the physician. Administer Lispro. Explanation: The client is experiencing ketoacidosis. The first action is to initiate I.V. fluids to prevent further dehydration. Next, the nurse should obtain serum glucose values to report to the physician, who will then order the appropriate dose of insulin
A client who has undergone a mitral valve replacement has persistent bleeding from the sternal incision during the early postoperative period. The nurse should do which of the following? Select all that apply. a) Start a dopamine drip for a systolic BP < 100. b) Monitor the mediastinal chest tube drainage. c) Administer warfarin (Coumadin). d) Confirm availability of blood products. e) Check the postoperative CBC, INR, PTT, & platelet leve
The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR and PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and severity of bleeding, therefore availability of blood products should be confirmed by calling the blood bank. Close monitoring of blood loss from the mediastinal chest tubes should be done. Coumadin is an anticoagulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should NOT be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done first. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine.
A client was recently diagnosed with a deep vein thrombosis in the right leg. The nurse should incorporate which of the following activities into the client's plan of care? a) Encourage the client to ambulate twice a shift. b) Assess the edema of the right leg every 4 hours. c) Have the client do active leg exercises hourly with both legs. d) Keep the right leg elevated above heart level.
Keep the right leg elevated above heart level. Explanation: The extremity should be kept elevated with heat applied to treat the inflammation and pain. To decrease chances of dislodging a thrombus, the client is typically kept on bed rest during the initial stages of treatment until therapeutic levels of anticoagulation are achieved. The client may exercise the unaffected leg but not the one with the deep vein thrombosis. Assessing the edema of the right leg is an essential activity, but it is the responsibility of the nurse to perform this task.
Which of the following compensatory actions by the body would occur if a client were in respiratory acidosis?
Retention of HCO3- by the kidneys. Explanation: The compensatory mechanism for respiratory acidosis is the renal system. In respiratory acidosis, the kidneys will conserve HCO3- in an attempt to correct the acidosis. Excretion of HCO3- would exacerbate the body's acidosis. The lungs cannot compensate for a problem that arises in the respiratory system
A client experiencing a severe asthma attack has the following arterial blood gas: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3- 26 (26 mmol/L). Which of the following orders should the nurse perform ?
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.
Which of the following physical sensations will the client who has had an abdominal hysterectomy most likely experience if she hyperventilates while performing deep-breathing exercises?
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
A client at 28 weeks' gestation presents to the emergency department with a "splitting headache." What actions are indicated by the nurse at this time? Select all that apply. a) Assess the client for vision changes or epigastric pain. b) Obtain a nonstress test. c) Determine if the client has a documented ultrasound for this pregnancy. d) Reassure the client that headaches are a normal part of pregnancy. e) Assess the client's reflexes and presence of clonus.
Headaches could be a sign of preeclampsia or eclamplsia in pregnancy. The client should be assessed for headache, vision changes, epigastric pain, hyperreflexes, and clonus. Her fetus should be assessed using a nonstress test. An ultrasound in this pregnancy does not give information to assess the presence of preeclampsia/eclampsia
A multigravid client thought to be at 14 weeks' gestation reports that she is experiencing such severe morning sickness that she "has not been able to keep anything down for a week." The nurse should assess for signs and symptoms of which of the following?
Hypokalemia. Explanation: Gastrointestinal secretion losses from excessive vomiting, diarrhea, and excessive perspiration can result in hypokalemia, hyponatremia, decreased chloride levels, metabolic alkalosis, and eventual acidosis if precautionary measures are not taken. Ketones may be present in the urine. Dehydration can lead to poor maternal and fetal outcomes. Persistent vomiting can lead to hypocalcemia, not hypercalcemia. Hyperbilirubinemia, not hypobilirubinemia, is typical in clients with hyperemesis. Persistent vomiting may affect liver function and subsequently the excretion of bilirubin from the body. Hypoglycemia, not hyperglycemia, may occur as a result of decreased intake of food and fluids, decreased metabolism of nutrients, and excessive vomiting.
The major goal of nursing care for a client with heart failure and pulmonary edema is to: a) Increase cardiac output. b) Decrease peripheral edema. c) Enhance comfort. d) Improve respiratory status.
Increase cardiac output. Explanation: Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmonary edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respiratory status and comfort will be improved when cardiac output increases to an acceptable level. Peripheral edema is not typically associated with pulmonary edema.
Which of the following explains the influence of aging on the development of peripheral vascular disease? a) Decreased viscosity. b) Increased viscosity. c) Increased resistance. d) Decreased resistance.
Increased resistance. Explanation: As people age, the accumulation of collagen in the intima of the blood vessels results in the vessels' becoming stiff and less flexible. Consequently, there is an increased resistance within the aging adult's circulatory system
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
Light-headedness or paresthesia 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. (less)
A client who chronically snorts cocaine is brought to the emergency department due to a cocaine overdose. The client is experiencing delusions, hallucinations, mild respiratory distress and mild tachycardia initially. The nurse should do which of the following? Select all that apply.
Place seizure pads on the bed. • Administer PRN haloperidol (Haldol) as ordered. • Monitor for respiratory acidosis. • Encourage deep breathing. • Monitor for metabolic acidosis. Explanation: The cocaine was not swallowed so inducing vomiting is not indicated. A cocaine overdose can produce seizures, paranoia, and respiratory and/or metabolic acidosis. Deep breathing will help decrease the respiratory distress and pulse rate.
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?
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. (less)
Which of the following factors contribute to a risk for amputation in a client with peripheral vascular disease? Select all that apply. a) A serum cholesterol concentration of 275 mg/dL (15.3 mmol/l). b) Current age of 39 years. c) A 20-pack-year history of cigarette smoking. d) Work that requires prolonged standing. e) Uncontrolled diabetes mellitus for 15 year.
Uncontrolled diabetes mellitus for 15 year. • A 20-pack-year history of cigarette smoking. • A serum cholesterol concentration of 275 mg/dL (15.3 mmol/l). Explanation: Uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular disease because of the macroangiopathic and microangiopathic changes that result from poor blood glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease; nicotine is a potent vasoconstrictor. Serum cholesterol levels greater than 200 mg/dL (11.1 mmol/l) are considered a risk factor for peripheral vascular disease. Typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease. Prolonged standing is a risk factor for venous stasis and varicose veins.
